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Podcast episode: Managing Mental Health and Behavior in the k-8 Classroom

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Podcast episode: Managing Mental Health and Behavior in the k-8 Classroom

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CHC Podcasts presents Voices of Compassion | Children's Health Council

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Today's episode was developed in response to a request from our partners at Palo Alto Unified School District...and while it's great for all listeners, is intended especially for teachers!

Increasingly, educators are being asked to manage not just the academic and social-emotional wellbeing of their students, but also address mental health challenges and learning differences in the classroom. We know it's not possible to do it all, but today's podcast episode shares some structures and strategies to support struggling students and promote a safe, positive learning environment for all. In addition to tips and takeaways, CHC's Esther B. Clark (EBC) Schools staff Krislyn Li Conklin, MA and Kaila Sugiyama, MA, LMFT, remind teachers that "recognizing your own humanity in all of this is the most important."

Krislyn studied at San Jose State University for both her Bachelor of Science and Master of Art degrees. She is a licensed education specialist under the California Commission on Teacher Credentialing. She has loved helping her students learn and grow at EBC school since 2018.

A Bay Area native, Kaila has been working with individuals and their families in the mental health setting for the last seven years. Prior to her work at EBC, Kaila was a counseling associate for a local school district providing individual, group and family therapy for students K-8. It is her firm belief that every individual has the potential for growth, change and success.

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Managing Mental Health and Behavior in the K-8 Classroom - CHC Podcasts presents Voices of Compassion | Children's Health Council

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Today's episode was developed in response to a request from our partners at Palo Alto Unified School District...and while it's great for all listeners, is intended especially for teachers! Increasingly, educators are being asked to manage not just the academic and social-emotional wellbeing of their students, but also address mental health challenges and learning differences in the classroom.

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Canada's Guide for Educators with lesson plans

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Canada's Guide for Educators with lesson plans

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Educator resource guide - School Mental Health Ontario

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Welcome to the Educator Resource Guide from School Mental Health Ontario (SMH-ON). This guide is designed to connect educators with the resources and tools they need to support student mental health. Start by using the reflection tool to the right. This tool will prompt you to think about your current practices, and explore areas that [...]

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In this podcast, we talk with school administrators, educators, clinicians, and parents to open a dialogue that will help the growing number of students struggling with mental illness.

In this podcast, we talk with school administrators, educators, clinicians, and parents to open a dialogue that will help the growing number of students struggling with mental illness.

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conversations about student mental health

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‎Conversations About Student Mental Health on Apple Podcasts

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In this podcast, we talk with school administrators, educators, clinicians, and parents to open a dialogue that will help the growing number of students struggling with mental illness.

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Center for Mental Health in Schools (Don't be fooled by the 1980's website design! Lots of great stuff here!)

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Center for Mental Health in Schools (Don't be fooled by the 1980's website design! Lots of great stuff here!)

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ucla center for mental health in schools

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UCLA School Mental Health Project Homepage. The UCLA Center for Mental Health in Schools is one of two national training and technical assistance centers focused on mental health in schools.* Our center approaches mental health and psychosocial concerns from the broad perspective of addressing barriers to learning and promoting healthy development.

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Written by Cassie (Teach Starter)

Put simply, mindfulness is "to pay attention, on purpose, to the present moment" (Grossman, 2016).
Make your classroom buzz! Subscribe to Teach Starter and access thousands of curriculum-aligned resources and digital learning tools. Get Started

The positive benefits of teaching mindfulness to children have been proven across a number of studies. Incorporating mindfulness activities for kids into an everyday classroom context is becoming more and more common. A five or ten-minute daily mindfulness practice can help students reduce stress and anxiety, increase concentration and engagement, sleep better, improve social skills, and develop problem-solving and decision-making skills.

5-10 Minute Mindfulness Activities for Children

Here are 18 quick and effective mindfulness activities you can do with your class. These activities are also available as a printable teaching resource, Mindfulness Activity Task Cards.

If you have never practiced mindfulness activities before you may like to:

Breath Awareness Activities

These are the first stop on your students' journey to mindfulness. Their breath is the one thing that will always be with them.

Explicitly teaching mindful breathing is providing students with a skill that will be with them for life, in every situation they will ever encounter.

Is that not one of the most powerful lessons you can ever teach?

Students can stand or sit for this activity.

Ask students to put both hands on their belly.

Students should close their eyes, or look down to their hands.

Guide students in taking three slow deep breaths in and out to see if they can feel their hands being moved.

You may like to count "1, 2, 3" for each breath in and "1, 2, 3" for each breath out, pausing slightly at the end of each exhale.

Encourage students to think about how the breath feels, answering the following questions silently, in their mind.
- What is moving your hands? Is it the air filling your lungs?
- Can you feel the air moving in through your nose?
- Can you feel it moving out through your nose?
- Does the air feel a little colder on the way in and warmer on the way out?
- Can you hear your breath?
- What does it sound like?

If you'd prefer not to wing it, download and print our Mindful Breathing Guided Meditation Script.

#2 Pinwheel Breathing
(5 minutes)

Providing students with an object to focus on is a great way to encourage concentration during mindfulness activities for kids. Use pinwheels in conjunction with the mindful breathing exercise above, making the pinwheel spin with every exhale.

We have created a beautiful, pinwheel template that combines mindfulness coloring with this simple craft activity.

#3 Belly Buddies
(10 minutes)

Ask students to bring in a small stuffed toy, or provide a class set of small, light-weight objects such as small bean bags or wooden blocks.

Students lay on their backs and place the toy or object on top of their belly buttons.

Take students through the guided breathing activity above, asking them to watch the object as it moves up and down with their breath.

#4 Shark Fin
(2 minutes)

Coined by former Mindful Schools co-founder Laurie Gossman and Mr Musumeci's Grade 5 class of the book "Master of Mindfulness: How to Be Your Own Superhero in Times of Stress" fame, the Shark Fin is a fantastic tool that you can use during any quick moment in your day. It will help to calm your class, or individual students, when their minds and bodies may be fighting against them.

Place the side of your hand on your forehead, with your palm facing out to the side.

Close your eyes.

Slide your hand down your face, in front of your nose.

Say "shhh" as you slide your hand down your face

If you are sitting down, you do the 5 Ss while you move your hand: Sit up straight, sit still, sit silently, soft breathing, shut eyes.

If you are standing do the same but you are standing straight, still, silently, using soft breathing, and shut eyes while you move your hand down your face.

"Master of Mindfulness" (Grossman & Alvarez, 2016)
This activity is similar to the first mindful breathing activity, however it uses visualizing colors as a means to increase focus and awareness. You may like to download our printable Breathing Colors Guided Meditation Script.

Ask students to think of a relaxing color. It can be any color they like, as long as it is one that makes them think of relaxation.

Ask students to think of a color that represents stress, sadness, or anger. Whichever of those emotions is most relevant or suitable for your class group to explore.

Students imagine breathing in the relaxing color and visualize it filling their lungs.

Students then imagine breathing out the stress, sadness, or anger color.

Your spoken instructions may be along these lines:

1. Imagine you are surrounded by the relaxing color. No longer is the air clear, it is the relaxing color.

2. You can still make out shapes, but your world is now a different color.

3. Imagine that as you breathe in, you breathe in this color too.

4. See the color filling up your lungs.

5. Imagine as you breathe out, that your breath is the color of stress.

6. See the stress color mix into the relaxing color around you. Watch the stress color slowly disappear.

7. Breath in your relaxing color.

8. Breath out the stress color.

#6 Breathing Hands
(2 minutes)

Spread one hand out like a star.

Use the index finger on your other hand to trace the outline of your star hand.

Take a deep breath in as you move to the top of your thumb.

Breathe out as you move down between your thumb and first finger.

Take another breath in as you move to the top of your first finger.

Breathe out as you move down between your first and second finger.

Repeat until you have taken five slow, deep breaths.

#7 Back-to-Back Breathing
(10 minutes)

Students work in pairs for this partnered breathing activity.

Sitting tall, with their back resting against their partner's back, begin the mindful breathing from activity #1.

Encourage students to notice their partner's breath.
- Is it shallow or deep?
- Fast or slow?
- Can they feel their partner's back moving as they breathe?

After a little while, students may find that their breath falls into sync with their partner.

Or it may not! These are all talking points for bringing awareness to the breath, in the present moment.

You could incorporate your Mindfulness Pinwheels into this activity too.

(Jennifer Cohen Harper, Little Flower Yoga)
This is a fantastic mindfulness activity that students can "take home" with them. It can be particularly useful to do a body scan to help relax before sleep. Download our printable Body Scan Guided Meditation Script to use with your class.

Students lay on the floor, with their eyes closed if they are comfortable (or they may prefer tolook at the ceiling).

Encourage students to pay attention to their feet for 5 or 10 seconds.
Questions to ask during a body scan:
- How does this body part feel?
- Is it cold or warm?
- Does it feel tight or relaxed?
- Is all or part of that body part touching the floor?
- Or clothing?
- What does that feel like?

Move on to their toes, then ankles, then calves and knees. Continue body part by body part until you reach the head.

Question how each part of the body feels to bring students' awareness to their body in the moment.

If there is tightness or stress, imagine breathing the stress out of that part of the body with each exhale.

Practicing Active Mindfulness

Mindful breathing is arguably the most important skill you can teach your students when it comes to mindfulness. However, being able to incorporate into everyday activities the calm and focused state of mind that the breathing activities practice can be viewed as a more tangible end-goal.

The following 'active' practices help to hone the skill of mindful action. Some students who struggle with the 'still' mindfulness activities for kids may be more likely to feel successful during active practices.

#9 Mindful Eats
(5 minutes)

This is a great activity to bring attention to how mindlessly we sometimes eat! Whether sitting in front of the TV, chatting to friends at lunch, or scrolling through something on the internet or social media, we often "switch off" when eating because it is such a familiar action.

Mindful eating can combat over-eating, it helps bring our attention to the flavors and tastes of different foods and helps us to realize what effects different foods have on how our bodies feel.

Students need something small to eat for this activity. Often a square of chocolate is a fun "challenge", although you could provide a piece of fruit or any food item that you feel will work with your class. Be sure to take any allergies into consideration!

Begin this practice with three deep breaths, or the Shark Fin activity (#4 above).

Direct students to take small nibbles or bites of the food.

Bring awareness to the sensations of eating.
- What is the taste like? Is it sweet or savory?
- What does the food feel like on your tongue?
- Do you need to crunch it between your teeth, or can you slowly dissolve it in your mouth?
- Try taking a slightly smaller or slightly larger bite.
- How does this change the way eating this food feels?
- Notice which muscles in your mouth, neck, and body move as you swallow the food.
- Pause between each bite and notice any changing sensations in your mouth or body.

#10 Mindful Steps
(10 minutes)

This activity is best completed outdoors and if suitable, students may like to walk barefoot.

Give students a clear boundary for where they can walk during this activity.

Each student selects a small area where they can walk in a line for about 5 or 6 steps and back then back to where they started without getting into another person's way.

Begin this practice with three deep breaths, or the Shark Fin activity (#4 above).

Take 5 or 6 steps in one direction, turn slowly and then take 5 or 6 steps back to where you started.

While walking, students bring their awareness to their breath and their body.
- What does the ground feel like under your feet?
- Which part of your foot touches the ground first when you take a step?
- Does your body feel heavy or light today?
- Are you slouching when you walk?
- Or, is your back up quite straight?
- Try not to change the way you walk, but instead just notice how your body naturally moves.

#11 Mindful Sounds
(2 minutes)

For this mindfulness activity, you will need something that makes a bell sound. There are some great meditation apps that have recorded bell, meditation cymbal, and singing bowl sounds, however, if you can have one of these small instruments in real life, the sound is much better!

Begin this practice with three deep breaths, or the Shark Fin activity (#4 above).

Give the following instructions before ringing the bell:
- When I ring the bell concentrate on the sound that you hear.
- Pay attention to whether you hear it louder in one ear than you do in the other.
- Keep your eyes closed until the sound is completely gone.
- If you notice your thoughts wandering, just bring your attention back to the sound of the bell.
- After you open your eyes, remain silent until you hear my voice again.

Students close their eyes, while the teacher rings the bell.

The activity is finished when the sound has completely dissipated.

#12 Spidey Senses
(5 minutes)

Karen Young from Hey Sigmund has a beautiful collection of mindfulness activities for kids on her blog. Spidey Senses is a fun way to frame this traditional mindfulness exercise. Our five senses poster and graphic organizer can be useful resources for teaching the senses to younger students.

Ask students to switch their senses up to a superpower level, just like Spiderman.

In this moment,
- What can they hear?
- What can they see?
- What can they taste?
- What can they smell?
- What can they feel?

Guide students as they stay in this Spidey state for 2-3 minutes.

#13 Gratitude Practice
(5-10 minutes)

Students use a notebook or a folder and paper to make a Gratitude Journal.

Practice gratitude journaling at a regular time each day, perhaps first thing in the morning, after lunch, or just before the end of the day.

Take five minutes to think of something that you feel grateful for today. Here are some topics or ideas you can use to guide your students:
- Something that someone else did for you that day.
- A person in your life that you appreciate.
- An activity or hobby you are grateful to be able to do.
- A positive quality of someone that can sometimes be hard to get along with.
- A skill or ability you have.
- A part of your body you are grateful for and why.
- An item that you love.
- Something that made you laugh.
- What you have learned from something that was hard.

Another beautiful idea is for each student to put their day's thanks into their own Gratitude Jar, or to create a Gratitude Tree, where each day's thanks is written onto a 'leaf'. This could either be on a notice-board or be hanging on a string from the limb of a real plant or tree branch. (Mayuri Gonzales, Little Flower Yoga)

#14 Glitter Bottle
(5 minutes)

Use this familiar sensory bottle concept as a mean to explicitly teach how mindfulness can help to calm us when we are feeling stressed, anxious, sad, or angry.
Preparation

Fill a bottle or jar with water, leaving a 1-inch space at the top.

Add a generous amount of glitter glue to the bottle (or a combination of Elmer's glue and regular glitter).

Seal the bottle well!

You may like to make one large bottle to use as an example for whole-class instruction, or a set of bottles that can be used by individuals or for small group rotations.

Directions

Shake the bottle well to mix the glitter, water, and glue.

Share the following words with your students:

"Imagine that the glitter is likeyour thoughts when youre stressed, mad, or upset. See how they whirl around and make itreally hard to see clearly? Thats why its so easy to make silly decisions when youre upset because youre not thinking clearly. Dont worry this is normal and ithappens in all of us (yep, grown-ups too).

[ Now put the jar down in front of them.]

Now watch what happens when you're still for a couple of moments. Keep watching. See how the glitter starts to settle and the water clears? Yourmind works the same way. When you're calm for a little while, your thoughts start to settle and you start to see things much clearer."
(by Karen Young of Hey Sigmund)
#15 Mindful Safari
(10-30 minutes)

Another beautiful child-friendly reframing of a traditional mindfulness practice is to take your students on a Mindful Safari.

Instruct students to remain quiet, calm their thoughts, and move slowly while on safari.

Ask students to turn their sense of sight, touch, and sound onto high.

Search for beautiful natural objects to explore.
- What does it look like?
- What color is it?
- What does it smell like?
- Can I touch it?
- What does it feel like?

Search for mini-beasts and other creatures that move.

When they find a creature, encourage students to watch the creature in silence for as long as they would like to.
- What does it look like?
- How does it move?
- What colors can you see on its body?

#16Sense Countdown
(5 minutes)

A great one for older students is an extension of the Spidey Senses activity. It can be used to help calm a busy mind and bring our awareness to the present moment.

Think of:

5 things you can see

4 things you can touch

3 things you can hear

2 things you can smell

1 thing you can taste

#17 Heartbeat
(5 minutes)

Our heartbeat is an amazing representation of our emotions. Like our breath, it is always with us. So, we can use our heartbeat to connect with the present moment in times of difficulty or stress.

You might like to begin this practice with three deep breaths, or the Shark Fin activity (#4 above).

Students place their fingers or hands over the part of their body where they can best feel their pulse.
- on the side of their neck, under their jaw
- inside their wrist
- or, over their heart

Ask students to close their eyes and notice how quickly or slowly their heart is beating.

Encourage them to think about their current state of emotion and consider if this might be connected to how quickly or slowly their heart is beating.

Direct students to stand and jump up and down on the spot ten times.

Students return to sitting and feel their heartbeat again, noticing any changes.

Students may like to close their eyes and focus on their heartbeat until it slows back down.

#18 Add a Touchy Feely Focus
(5 - 10 minutes)

Saving the best for last, Shakti Burke gives these great tips for helping wiggly kids begin to master mindfulness. Burke suggests:

Restless minds are magnetized by the sensation of touch: we cant think and feel at the same time. The stroking and feeling itself (when using a prop to help children focus) becomes the meditation, in place of the breath awareness focus.

You might like to begin your class journey toward mindfulness with some of these more tactile activities.
Provide students with a prop to hold, touch, balance, or focus their eyes on during one of the above activities.

small soft toys

small bean bags or beanie pillows

stress balls

pieces of furry fabric

There you go! 18 amazing activities to help teach mindfulness in your classroom. Mindfulness truly is a skill that will benefit your students as individuals, long after they leave your classroom for the final time.

Check out our beautifully illustrated Mindfulness Activity Task Cards that you can use to support mindfulness practice with your students.

Whole Class Daily Mindfulness Activity Tracker

Track your class' progress to superhero status with these beautiful Mindfulness Activity Tracker Charts that can be used to note each day of whole-class practice.

The charts are available in three formats:

Each download comes with a page of illustrated markers that can be stuck onto the chart. The black and white downloads of these trackers are also fantastic for students to use for their personal mindfulness practice.

If you are new to mindfulness for children, take a look at our post "Why You Should Be Teaching Mindfulness to Improve Student Learning" for practical tips and tricks to begin your class mindfulness practice routine. You can also download our Mindfulness Information Sheet for Teachers with eight succinct and actionable tips.
Make your classroom buzz! Subscribe to Teach Starter and access thousands of curriculum-aligned resources and digital learning tools. Get Started

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5 Minute Classroom Mindfulness Activities for Kids

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Written by Cassie (Teach Starter) Put simply, mindfulness is "to pay attention, on purpose, to the present moment" (Grossman, 2016). Make your classroom buzz! Subscribe to Teach Starter and access thousands of curriculum-aligned resources and digital learning tools. Get Started The positive benefits of teaching mindfulness to children have been proven across a number of studies.

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In our world today, people's lives are busy, whether with work, family, school, hobbies, or other activities. Within our daily environments, it may seem as though there is limited time for our mental health and wellbeing, unless we are proactively creating this space for ourselves. Additionally, there is a clear stigma that invades schools and workplaces, making administration unwilling or unable to present adequate solutions or positive change.

I believe that it is essential for environments -- particularly schools and workplaces -- to implement strategies to consistently and effectively support the wellbeing of their students and employees.

Schools Should be at the Frontline of Mental Health Awareness

Schools are meant to be places for social and academic growth. As spaces for development, schools are most beneficial to students who are able to harness a growth mindset -- ready to embrace the classes they are in, believe in their abilities, and maximize their own learning. This mindset goes hand-in-hand with an individual's ability to practice self-care and self-love. If an individual can first learn to accept themselves and take care of themselves, then they can move forward to improving themselves. In a classroom setting, this means that they can advance to learning new concepts, thinking critically, and growing alongside their peers.

As Shawn Achor, author of The Happiness Advantage says; "Focusing on the good isn't just about overcoming our inner grump to see the glass half full. It's about opening our minds to the ideas and opportunities that will help us be more productive, effective, and successful at work and in life."

Therefore, schools should prioritize their students' wellbeing and give each and every one of their students the opportunity to "focus on the good". This will lead to a school full of more productive and prepared students. Below are five ideas that I have for schools to offer solutions on supporting their students' mental health, and although these solutions may generally require administrative approval, student voice is powerful in initiating this positive change.

1: Implement time and safe spaces in class for regular check-ins with students

If teachers are able to get a glimpse into how their students are doing, this will help them to not only build more of a connection with their students, but also to understand their students' behaviors and participation efforts more holistically.

Checking in as a class can also allow for students to feel less alone. Upon seeing that their classmates are not all as "perfect" and "great" as they appear, students may feel relief and hopefully will seek support if needed.

In general, check-ins allow for a healthier classroom environment where teachers are more aware of their students' circumstances and students are able to harness peer connection in breaking down the stigma around feeling "not ok" at times.

2: Give basic mental health training to all teachers

When teachers create safe spaces for check-ins in their classroom, they may come across students who show red flags in regards to their mental state, or students who may just need some extra support. If this is the case and teachers are equipped with basic mental health training, they will be able to act accordingly and connect their students to help and resources well before their mental health state escalates to worse.

Teachers who are observant and trained to look for warning signs for may be able to notice changes in their students' behavior. If they are trained, they will feel confident in their ability to address a student's check-in and to refer their student to professional resources if and when necessary.

3: Give basic mental health training to all students

Similar to training teachers, training students on how to support their friends' or peers' mental health is crucial. Students can often be the first-responders in cases like this. It's important to emphasize that neither students nor teachers are clinicians. They are not being trained to treat anyone. Instead, they are being treated to observe signs and react accordingly, by referring out to professional resources, people, or centers.

This system will allow for less students to fall through the cracks when it comes to their mental health, since everyone will be watching out for each other -- a peer-to-peer network of mental health care.

4: Have a wellness center on-campus, designed by students and easily accessible to all students.

Similar to creating spaces within the classroom for wellness check-ins, having an actual physical space on campus for student wellness is essential in supporting students. This on-campus wellness center serves as a place where students can go for a variety of activities, such as having a simple conversation with a peer, connecting with a professional, learning about self-care, drinking tea, doodling in coloring books, resting, or meditating.

The center should be designed by students at the school, in order to have it in a place where students will actually use it and to make the center's services relevant for all other students. Administration should implement a policy that states that students may visit the wellness center during class if they need to for any reason.

5: Have regular open events for parents to attend to learn more about student mental health and how to support their child.

Bridging the generation gap between students and parents is vital in order to foster an understanding relationship. Since schools do not have as much influence over what goes on at home, offering resources for parents to better understand how to support youth mental health will create a fluid transition for students between school and home life.

Parents often deeply want to help and support their kids, yet they may not know which resources to turn to regarding mental health. Schools can inform parents and households on the general foundation of mental health support and where to seek more professional help, if and when necessary.

These are just five ideas for schools to better support their students' wellbeing. Some schools are already beginning to implement solutions similar to these, however, there is always room for improvement on more effective support systems for students everywhere. Now that we have explored the environment of schools, my next article will outline five ideas for workplaces to better support their employees.

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5 Ways Schools Can Support Student Mental Health - Drug Rehab Options

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In our world today, people's lives are busy, whether with work, family, school, hobbies, or other activities. Within our daily environments, it may seem as though there is limited time for our mental health and wellbeing, unless we are proactively creating this space for ourselves.

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Leading Trauma-Sensitive Schools | National Center on Safe Supportive Learning Environments (NCSSLE)

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Leading Trauma-Sensitive Schools The Leading Trauma-Sensitive Schools component of the Training Package is designed for school and district administrators and other school staff helping to lead efforts to adopt a trauma-sensitive approach. Resources are designed to help leaders:

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Advancing Comprehensive School Mental Health Systems

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A suite of programs designed to allow educators to empower their students with an introduction to mental health, depression-literacy, help-seeking and what it takes to promote good mental health. Focused on grades 4-12, these no-cost, skills-based programs use diverse teen voices to spread awareness and reduce stigma.

We All Have Mental Health

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A deeper discussion about depression and suicide along with a strong focus on help-seeking and good mental health.

How Erika's Lighthouse Programs Work For Your School

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Every school is different. Our videos, lesson plans, and assessments allow educators to adapt materials according to the needs of their classrooms so that we can forge a healthy environment for students to talk to educators, and to each other.

Ready to Go Materials

Our videos and lessons are completely turnkey: they're ready for you to use as soon as you set up an account. Opening up begins immediately.

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Some schools only have a day to discuss mental health. Some schools don't benefit from small group work. Our material is adaptable to all situations. We want it to work for you.
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All-inclusive support, at no cost. We work with you on best practices, how to adapt the materials, and how to raise awareness while raising hope.

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The way young people communicate with each other is always changing. School climate is always changing. Mental health research is always changing. That's why we're always changing.

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Depression Education is Suicide Prevention

Utilizing an upstream approach, depression education allows school communities to identify MORE students struggling with mental health challenges EARLIER than suicide prevention alone. This can result in early intervention and avoidance of suicidal ideations. Over 96% of students believe anxiety and depression are problems within their school building. Universal education around these topics is important, effective and necessary.
Read more about how we follow best practices in suicide prevention >

Mental Health Impacts the Whole Child

Our programs firmly center on the student, allowing them to find their voices and speak up about mental health. By building up students in their school, they have the ability to share their knowledge with the community around them, and in turn create a whole school and whole community that support their physical and mental health. These building blocks provide students the foundation to succeed and excel academically and socially.
Read more about how we fit within the WSCC Model >

Our Programs Bridge SEL and Mental Health

Social-Emotional Learning is key to student development, but SEL can only accomplish so much. In fact, mental health is an outcome of SEL. Our programs act as a bridge for students to put SEL into practice to benefit their mental health. Working with the CASEL 5 components - Erika's Lighthouse is helping schools to easily build on their programs and establish good mental health behaviors for students.

Nancy Watson, LCSW, CADC

Taking the stigma out of adolescent depression is our passion and our expertise.

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Classroom Education | Erika's Lighthouse

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A suite of programs designed to allow educators to empower their students with an introduction to mental health, depression-literacy, help-seeking and what it takes to promote good mental health. Focused on grades 4-12, these no-cost, skills-based programs use diverse teen voices to spread awareness and reduce stigma.

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There are many, many organizations and groups that deal with mental health. This page will help you find the one or ones that offer the type of assistance, intervention, or information you're seeking. We've organized the information into the following sections:

If It's a Crisis...

First things first, regardless of how frightening a note this is to begin on. If someone you know is having a mental health crisis and you need help fast, try the resources below that seem to fit the nature of the crisis.

Call 1.800.784.2433, the National Hopeline Network. You'll be connected automatically to a certified Crisis Center near your location. Crisis Center calls are answered by trained counselors 24 hours a day, 7 days a week. In the event that the nearest Crisis Center is at maximum volume, the call is seamlessly rerouted to the next closest center. Callers should never encounter a busy signal or voice mail. For easy recall, remember this: 1.800.SUICIDE. hopeline.com

Call 1.800.273.8255, the National Suicide Prevention Lifeline. Another excellent resource is the National Suicide Prevention Lifeline, which also provides access to trained telephone counselors, 24 hours a day, 7 days a week. For easy recall, think 1.800.273.TALK. For the same help in Spanish; call 1.888.628.9454. Individuals who are deaf or hard of hearing can contact the lifeline via TTY, at: 1.800.799.4889. suicidepreventionlifeline.org

Visit the American Association of Suicidology (AAS) online. AAC is dedicated to the understanding and prevention of suicide. For those seeking info and perspective on this difficult subject, including the warning signs and guidance on what to do, the association offers many publications that can help. www.suicidology.org

Find a residential placement for an individual. The Association of Children's Residential Centers concerns itself with therapeutic living environments for children and adolescents with behavioral health disorders. You can take a look at ACRC's member list to see what types of residential centers are available to help children who need this sort of residence. Find these detailed descriptions online at: togetherthevoice.org/our-members

A Quick-Read Fact Sheet

Read our fact sheet on emotional disturbance. If you're looking for an intro to emotional problems and the mental health field, this is a good place to start. Our fact sheet will hook you up with organizations that can help, online and print resources of more information, and an overview look at disabilities that cause mental health concerns. www.parentcenterhub.org/repository/emotionaldisturbance

Be Sure To Come Here

There are numerous sources of incredible information, support, and guidance on mental illness-across the gamut. We've listed a few starter links below where you can find out more about the range of specific mental disorders, interventions, family life, coping strategies, and much more.

National Federation of Families for Children's Mental Health (NFFCMH). The link below takes you to a wealth of resources for parents on specific mental health diagnoses as well as and other topics related to children's health and family involvement in systems that impact children. www.ffcmh.org/resources

MentalHealth.gov. MentalHealth.gov provides one-stop access to U.S. government mental health and mental health problems information. www.mentalhealth.gov

NAMI, the National Alliance for the Mentally Ill. NAMI calls itself the "Nation's Voice on Mental Illness" and is an invaluable source of information on the subject. In addition to the mountain of info you'll find on NAMI's site, you can also connect with state and local NAMI chapters. www.nami.org

Mental Health America. NMHA addresses all aspects of mental health and mental illness. Delve into their online resources about mental issues and identify NMHA affiliates in your area. www.nmha.org

American Academy of Child and Adolescent Psychiatry (AACAP). At the link below, you can find information on child and adolescent psychiatry, fact sheets for parents and caregivers, current research, practice guidelines, and managed care information, among other things. www.aacap.org

American Academy of Pediatrics (AAP). AAP offers the family-friendly site called Healthy Children, where you can find a wealth of information in English and Spanish about emotional problems in children. www.healthychildren.org/English/health-issues/conditions/emotional-problems/Pages/default.aspx

Mental Help Net. A vast amount of info here on specific mental disorders, mental health, wellness, and family and relationship issues and concerns. mentalhelp.net

National Mental Health Information Center. This service of the Substance Abuse and Mental Health Services Administration's (SAMHSA) provides information about mental health via a toll-free telephone number, more than 600 publications, and a website located at: www.samhsa.gov

National Institute of Mental Health (NIMH). Another very rich resource. At NIMH, you'll find health info on a very wide range of mental health disorders; all about different medications; and the latest info on clinical trials and research. Find all this-and publications in English and Spanish-at: www.nimh.nih.gov/health/index.shtml

Finding Mental Health Services

Find mental health services. The Center for Mental Health Services (CMHS) offers a state resource sheet for every state in the U.S., useful for identifying the range of agencies and mental health assistance that's available in the state and nationally. store.samhsa.gov/facet/Location

Health care insurance for uninsured children. Did you know that each state has a health insurance program for children? Children who don't have health insurance right now are very often eligible for state medical coverage. The insurance is available to children in working families, including families that include individuals with a variety of immigration status. To find out what your state's policies are, what's covered, and how to apply, call 1.877.543.7669 or find your state at: www.insurekidsnow.gov/state/index.html

Medicaid benefits for mental health services. If you're eligible for Medicaid, you may be able to access mental health services through Medicaid. States vary, however, in what types of mental health services they provide under Medicaid. Use the database at the link below to find what Medicaid benefits are available in your state. tinyurl.com/yhuos2j

Mental Health in Schools

Mental health in schools. Starting in 1995, two national training and technical assistance centers were established to improve how schools address barriers to learning and enhance healthy development. Each of these centers is a source of information and technical assistance regarding mental health in schools. Take advantage of each of their databases, materials, and expertise:

Center for Mental Health in Schools, UCLA smhp.psych.ucla.edu Under "Search and Quick Find" in the main menu, you can search the Center's resources for just about everything but the kitchen sink related to mental health in schools.

Center for School Mental Health Assistance, University of Maryland csmh.umaryland.edu This center maintains a library of resource materials including reprints, articles, and publications specific to school-based mental health. It also offers a comprehensive directory of school mental health programs around the world.

For educators. Educators are often the first to notice mental health problems. Here are some ways educators can help students and their families. From mentalhealth.gov. www.mentalhealth.gov/talk/educators/index.html

Organizations on Specific Disorders

Looking for info and assistance related to a specific mental condition? In addition to what you'd find by visiting the organizations listed above under "Be Sure to Come Here," look over the quick alphabetical list below of organizations that focus on a specific mental disorder. They offer in-depth information, support groups, and guidance regarding that disability-perhaps the one of concern to you.

Anxiety Disorders. Visit the Anxiety Disorders Association of America (ADAA). www.adaa.org

Behavior Disorders. Visit CPIR's Behavior Suite for a detailed list of resources and organizations addressing behavior disorders and concerns. www.parentcenterhub.org/repository/behavior

Bipolar Disorders. If this is your area of concern, try these groups.

Child & Adolescent Bipolar Foundation (CABF) www.bpkids.org

Depression and Bipolar Support Alliance (DBSA) www.dbsalliance.org/site/PageServer?pagename=home Toll-free number: (800) 826-3632.

Dually Diagnosed: Mental Illness and Intellectual Disabilities. www.thenadd.org The National Association for Dually Diagnosed (NADD) focuses upon the needs and issues of individuals who have both mental illness and cognitive impairments or intellectual disabilities, and the professionals and families who share concern for these individuals.

Eating Disorders. www.nationaleatingdisorders.org The National Eating Disorders Association (NEDA) works to prevent eating disorders and provide treatment referrals to those suffering from anorexia, bulimia and binge eating disorder and those concerned with body image and weight issues.

OCD, Obsessive-Compulsive Disorder. www.ocfoundation.org The Obsessive-Compulsive Foundation (OCF) is for people with obsessive compulsive disorder (OCD) and related disorders, their families, friends, professionals and other concerned individuals.

Post-Traumatic Stress Disorder (PTSD). www.ptsdinfo.org For more info and assistance on PTSD, you'll want to visit the Gateway to Post-Traumatic Stress Disorder (PTSD) Information.

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There are many, many organizations and groups that deal with mental health. This page will help you find the one or ones that offer the type of assistance, intervention, or information you're seeking. We've organized the information into the following sections: First things first, regardless of how frightening a note this is to begin on.

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The Short-and-Sweet IEP Overview | Center for Parent Information and Resources

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Over the past month, educators across the country have come up with creative ways to support the physical, mental and emotional wellbeing of children. From " teacher caravans " to virtual office hours, read alouds, and dance breaks, they have provided students with much-needed support to complement their education during a time of unprecedented disruption.

But what about the wellbeing of parents? Should schools play a role in supporting their wellbeing, too?

Whenever we board a plane, flight attendants tell us that if the oxygen masks drop, adults need to put their own masks on first. Similarly, parents need to take care of their own physical and emotional wellbeing before they can ensure their children can learn.

Research has shown that children do better in school, and are more likely to be physically and emotionally healthy, if their parents are also healthy. Conversely, when struggling with high levels of stress, parents find themselves with a reduced capacity to be emotionally engaged and responsive with their children. This emotional stress, often compounded by social isolation and difficulty accessing basic resources (such as food and housing), interferes with the adult's ability to engage with their child's education and wellbeing. In severe cases, it can lead to child abuse and neglect.

This is especially true in the current moment. Many parents, some of whom were already struggling to pay rent and put food on the table before the pandemic, have lost their jobs and taken on added financial and personal stress. Some of those still employed are working in higher risk environments, while juggling the responsibility of supporting remote learning. All of this is taking a significant emotional toll on parents, and their wellbeing must be a factor as schools engage in longer-term planning to support children and families.

One of the core pillars of our work at The Primary School is to help parents not only support their child's development, but also reflect on and address their own wellness. It is important, perhaps now more than ever, to recognize the inherent strengths of each parent while also tending to their personal development, motivation and self-actualization.

The program is offered at our school in East Palo Alto, California, where most of the community is low-income. Our approach is rooted in the belief that all families, regardless of circumstance, can benefit from coaching.

We are-thankfully-not alone in this belief. When we designed our parent coaching program, we incorporated best practices from programs in fields ranging from social work, behavioral change and psychology, to trauma-informed care and global poverty alleviation. For example, EmPath's comprehensive coaching program builds adult capacity to achieve long-term financial sustainability. Promotores, an initiative led by the U.S. Department of Health and Human Services, leverages community health workers to improve public health. We borrow lessons from the Community Schools Playbook to build relationships with families and connect them to resources through family resource coordinators. And our home visits are informed by the work of the Parent Teacher Home Visits program, Flamboyan Foundation and others who know the importance of house calls.

Key to making this work possible is maintaining regular touch points throughout the year. When families enroll their children in our school, every parent is paired with one of our parent wellness coaches (many of whom grew up in or live in the communities we serve) and connected to a parent circle, a group of 8-10 parents who meet monthly. A coach's primary role is to help families build their own self-efficacy, resilience, and social connections.

During the first week of shelter in place, our coaches were able to connect with 95 percent of parents to identify immediate needs and help them make a plan. In April, our coaches made 152 referrals to resources that span from housing to legal services to healthcare. This has helped families tremendously in getting access to accurate, reliable, and actionable information and support. All the while, coaches worked with parents to develop skills for stress management and other coping mechanisms to help mitigate the impact of the current environment.

Even in the light of a pandemic that no one could have prepared for, we have been heartened to watch the seeds that had been planted start to bear fruit. Parents have been able to access local resources in order to advocate for their basic needs so that even in the midst of this disruption, their children can continue learning.

Even without dedicated parent coaches, there are many ways that school leaders and teachers can support parents during this unusual and stressful time, and help them build life skills and resilient networks of support.

1. Ask families how they are doing: At your next check-in with parents, spend time asking about how they are doing-and not just if their children are learning.

How have you felt lately?

Have you gotten a chance to rest?

What is one thing that you have done for your wellbeing?

Schools will open up new opportunities for deeper engagement when adults are treated as individuals, not just as parents to their children.

2. Understand barriers and offer invitations for joint problem solving: If a student does not complete an assignment or lesson, consider the context of what else might be happening and how you can support a bigger picture. The root cause may be more complicated (e.g., a parent's job schedule, new or multiple caretakers in the home, or other stressors in the home that can impact the day's priorities). If educators seek to understand the broader picture, they can support families with problem solving.

3. Leverage local resources to support families: Be ready to share local resources that might be able to meet some of the immediate and concrete challenges families are facing, such as healthcare, legal, food and housing matters. Schools can rely on community agencies who already compile these resources; check the websites of your local governing agency, school district, family resources centers, and health care providers.

4. Emphasize and support mental wellness for adults and children: School staff can acknowledge and support the mental and emotional wellbeing of their families and children by providing kind and compassionate care. Share simple mindfulness exercises and stress reduction activities that parents can do on their own or with their children. Weave in socio-emotional focused activities in addition to academic content. We have curated some ideas here.

5. Develop and deepen parent support networks: School staff do not need to do this alone. Connecting parents to each other for peer support is a powerful way for families to share their own wisdom about accessing concrete resources, managing stress and navigating remote learning.

We hope that this unprecedented period in our history helps us reimagine how and why to support parents' wellbeing alongside the needs of our students, even after we move past this crisis.

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Supporting Students Means Taking Care of Parents, Too. Here's How Schools Can Help. - EdSurge News

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Over the past month, educators across the country have come up with creative ways to support the physical, mental and emotional wellbeing of children. From " teacher caravans " to virtual office hours, read alouds, and dance breaks, they have provided students with much-needed support to complement their education during a time of unprecedented disruption.

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Skills for Effective Parent Advocacy - Michigan Alliance for Families

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Real Actions School Leaders Can Take to Support Teachers

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A district superintendent shares several takeaways from talks with teachers about what they want to see from administration.

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Evidence Based Practice Unit (EBPU), University College London and Anna Freud National Centre for Children and Families (AFNCCF), London N1 9JH, UK

Research Department of Clinical, Educational and Health Psychology, Faculty of Brain Sciences, University College London, London WC1E 6BT, UK

Author to whom correspondence should be addressed.

1. Introduction

Improving young people's mental health and wellbeing has been identified as one of the key public health issues of our time, and recent prevalence findings show that one in eight young people experience mental health problems [ 1]. In the United Kingdom (U.K.), research has found that emotional problems such as anxiety and depression are the most common issues experienced by young people, followed by behavioural problems [ 2]. It is widely acknowledged that these difficulties may have a costly negative impact on educational attainment, drug use, criminality, physical health, poorer employment outcomes, not in education, employment or training (NEET) status, and financial difficulties [ 3, 4, 5, 6]. The World Health Organisation (WHO) has called for a coordinated response from different sectors of society, noting that "among all the sectors that play critical roles in adolescent health, education is key" [ 7] (p. 8).

Internationally, schools are increasingly being perceived as important sites to embed mental health and wellbeing prevention programmes, and a number of recent reviews have highlighted areas of promise in relation to school-based mental health support [ 7, 8, 9]. A recent systematic review carried out by the Early Intervention Foundation identified programmes for social and emotional skills and cognitive behavioural therapy (CBT) interventions for internalising symptoms to be particularly effective in improving mental health outcomes for children and young people [ 9]. Another review focusing on effective universal interventions for mental health and wellbeing noted that while the evidence base was still limited, there were a number of common practices, namely, that interventions were school-based and skills-based, often drew on CBT principles, included a discrete number of sessions, and were designed to be fun and engaging [ 10].

This emerging evidence base has coincided in the U.K. with an increased policy focus on schools as a site for mental health support. Recent examples in England include the Transforming Children and Young People's Mental Health Green Paper, which provided a framework for school mental health support through senior mental health leads in schools and mental health support teams, and the new Relationships, Sex and Health Education guidance, which incorporated the teaching of mental health into the curriculum guidelines [ 11, 12]. There have also been several government-commissioned programmes that attempt to embed mental health interventions in schools. Examples include Social and Emotional Aspects of Learning (SEAL), Targeted Mental Health in Schools (TaMHS) and, more recently, large-scale research programmes to test the effectiveness of universal mental health programmes [ 13, 14, 15, 16]. While popular during their initial delivery, many of these programmes report significant variation in intervention fidelity and seem to have a relatively short shelf-life once initial funding finishes [ 13].

Lack of sustained delivery is common across contexts and countries; whilst governments across the globe invest substantially in the roll-out of mental health promotion programmes in schools, there are "concerning reports, nationally and internationally, about poor programme sustainability once start-up enthusiasm and resources are exhausted" [ 17] (p. 2). It is clear from the considerable investment of resources and the evidence of the success of these interventions that it is in the best interest of the health and education systems, as well as individual schools and pupils, to achieve long-term sustainability of such programmes. Although this issue in schools is well recognised, and there is wider research literature on what affects sustainability and how sustainability of effective programmes can be improved, there has been limited focus on educational settings [ 18, 19].

Historically, research on sustainability has been fragmented and drawn from a variety of settings (predominantly in healthcare) which may or may not have parallels with the school context [ 18]. For wider health programmes, common factors that promote sustainability include workforce capacity, programme champions, organisational culture and context, evaluation and feedback, intervention effectiveness, staff turnover, and the wider political climate [ 18, 20]. In a recent review focusing specifically on health interventions in school settings, Herlitz et al. [ 19] found many similar factors affecting sustainability. However, this review also noted that academic education was, at times, prioritised over health interventions and that staff sometimes lacked confidence delivering health promotion programmes that were outside of their usual expertise [ 19].

There is an argument therefore to suggest that topics that are traditionally considered outside the scope of schools may be more difficult to sustain in these contexts. As previously mentioned, schools' mental health remit has recently changed to include educating pupils about mental health and wellbeing and providing support to children and young people. Consequently, it is important to understand just how much these wider factors around the sustainability of health interventions are relevant to mental health interventions in the school context. This review aims to contribute to the literature by identifying studies carried out in this area and addressing the question: what are the barriers and facilitators to sustaining school-based mental health and emotional wellbeing interventions?

2. Materials and Methods

A protocol for this systematic review was published on PROSPERO in August 2020 (ref: CRD42020189253), and relevant PRISMA guidelines for reporting were followed [ 21].

2.1. Definitions

Two of the key constructs in this review, 'mental health and emotional wellbeing' and 'sustainability', are not consistently defined and used in the literature [ 18, 22, 23, 24]. The term 'wellbeing' is interpreted differently in different fields and research disciplines, and the relationship between mental health and wellbeing is poorly defined [ 22]. However, for this systematic review, the constructs are used together in an attempt to capture articles on the range of interventions (discussed above) that are currently taking place in schools. As a result, specific terms associated with internalising (e.g., depression, anxiety, eating disorders) and externalising (e.g., behaviour problems, aggression, substance abuse) problems, along with broader terms such as 'mental health' and 'wellbeing', were included.

Of the various definitions and frameworks used to conceptualise the term 'sustainability', Wiltsey-Stirman et al. [ 18] identified the most cited definition in the literature as that proposed by Scheirer [ 25]. This defines sustainability on three different levels: (a) individual level: continuing to deliver the desired outcomes or benefits for individual community members; (b) organisational level: an organisation maintaining the programme or intervention in an identifiable form, even if modified; and (c) community level: maintaining the capacity of a community/region/nation to deliver programme activities after an initial implementation period is over [ 25]. This review draws on this definition but does not focus on the individual outcomes at the pupil level (a), as these outcomes are sometimes included in long-term follow-ups of intervention effectiveness studies. Instead, this review focuses on addressing the gap in understanding around sustained delivery of school-based mental health and emotional wellbeing interventions, and consequently, it centres on the organisational (b) and community (c) level factors that may affect sustainability.

This review employs the WHO's definition of a health intervention as "an act performed for, with or on behalf of a person or population whose purpose is to assess, improve, maintain, promote or modify health, functioning or health conditions" [ 26].

2.2. Study Eligibility

Studies were considered for inclusion if they met the following criteria:

(i)

The study focused on the sustainment of a school-based mental health or emotional wellbeing intervention, and research was carried out after the end of the initial implementation period (when initial funding and/or external support had ended).

(ii)

*

Targeted school-aged children and young people (CYP; between 4 to 18 years of age);

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Aimed to improve mental health and emotional wellbeing outcomes;

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Was delivered during school hours primarily by staff in or associated with the school (e.g., teachers, pastoral, managerial or administrative staff, health or wellbeing professionals employed or commissioned to work with the school) or students (e.g., peer mentors).

(iii)

Participants in the research were involved as receivers, developers, or evaluators (e.g., intervention developers, school staff, or researchers) of the school-based mental health or emotional wellbeing intervention.

(iv)

The study used quantitative or qualitative empirical methods to explore sustainability, or was a systematic review synthesising empirical studies.

(v)

The study was published in English since the year 2000

Studies were excluded if they reported only on the initial implementation phase of delivery or reported intentions to sustain or continue activities with no research conducted after initial funding and external support had ended. Studies that only reported outcomes on the individual level (pupil) at long-term follow-up, with no mention of programme activities, were also excluded. Interventions that were delivered primarily outside of school hours or by external providers (e.g., an after-school club in a community centre) were excluded as this review focused specifically on programmes delivered in the context of mainstream education.

2.3. Search Strategy

The following electronic databases were searched on 3rd and 5th March 2021 for potentially relevant studies: PsycINFO, MEDLINE, Embase, British Education Index, ERIC, and Social Sciences Citation Index and Conference Proceedings Citation Index - Social Science and Humanities (Web of Science). Each database was searched to find articles containing terms related to four key components: sustainability, school, intervention, and mental health/emotional wellbeing (see Supplementary Material File S1 for an example search strategy). A grey literature search was also conducted by identifying key websites (see Supplementary Material File S1). Additionally, the reference sections of included studies were checked, and a citation search was conducted on Google Scholar.

2.4. Screening

Results from the database searches were uploaded to the review management software EPPI-Reviewer Web [ 27] and duplicates were removed. All titles and abstracts were screened by the lead author (AM). The fourth author (RT) independently screened 10% of the studies at the title and abstract stage, and an interrater reliability analysis using the kappa statistic was performed to determine consistency among raters (k = 0.84, p = 0.001). Any discrepancies were resolved through discussion with the other authors, and AM went on to screen the remaining titles and abstracts. Full-text copies of the remaining articles were retrieved and screened by AM. RT also assessed 10% of the full texts (k = 0.82, p = 0.001), and the final decisions on included articles were made collectively as a research team.

2.5. Quality Assessment

Quality assessment of included articles was conducted using the Mixed Methods Appraisal Tool (MMAT; [ 28]). This tool, designed to appraise the methodological quality of research studies, allows for simultaneous evaluation of all empirical literature (i.e., qualitative, quantitative, and mixed methods studies) which was appropriate for this review. The MMAT has high intraclass correlation and has been shown to be efficient and user-friendly [ 29]. Quality scores for each article ranged from meeting none of five criteria (zero) to meeting all five criteria (five). Articles scoring zero to one are described as 'low' quality, two to four as 'medium' quality and five as 'high' quality.

2.6. Data Extraction and Data Synthesis

A data extraction table was designed specifically for this review, drawing on best practice guidance [ 30]. Extracted variables included: geographical location; description of school-based intervention (aim, population, and design); sustainability definition; sustainability study population, sample size, and data collection methods; and factors affecting sustainability.

Due to the lack of homogenous quantitative studies, it was not possible to conduct a meta-analysis; no two studies in this review used similar measures that could be compared quantitatively. Consequently, the results sections of quantitative, qualitative, and mixed-methods studies were imported into the data analysis software NVivo [ 31]. A thematic analysis was conducted by the primary researcher (AM) using the six steps identified by Braun and Clarke [ 32]. AM read and re-read the data (Step 1) and conducted line-by-line inductive coding of the included results sections (Step 2). ES also conducted the same coding process on 20% of the articles, and potential themes were created and discussed (Step 3). AM then continued reviewing and refining themes and created a thematic map and detailed corresponding table. The synthesis was then discussed with ES, JD, and DH before the final write up of the results section (Step 6).

3. Results

Of the 6160 articles identified through database searching, 10 articles met inclusion criteria and provided information that could be extracted on factors affecting sustainability (see Figure 1).

3.1. Study Characteristics

The country with the majority of the included studies was the United States (U.S.), with six articles [ 33, 34, 35, 36, 37, 38]. The remaining studies were conducted in Germany [ 39], Norway [ 40], the Netherlands [ 41] and the U.K. [ 42].

Studies presented findings on a range of different school-based programmes, including interventions aimed at reducing symptoms of eating disorders and weight control behaviours [ 34, 39]; CBT-informed interventions to treat pupils experiencing trauma, anxiety, and depression [ 33, 37, 38]; interventions addressing behaviour problems [ 35, 36, 40, 41]; and a broader screening tool focused on social, emotional, and mental health needs [ 42]. See Table 1 for a summary of intervention characteristics and reported effectiveness.

3.2. Sustainability Terms and Definitions

Four articles used alternative terms to refer to sustainability, including 'long-term implementation' [ 39], 'continuation' [ 40], 'maintenance' [ 35], and 'de-adoption' [ 37]. LoCurto et al. [ 38] referred to 'sustained use' of the intervention, while the remaining five articles used the term 'sustainability' throughout [ 33, 34, 36, 41, 42].

The timeframe between the initial implementation period and the sustainability evaluation varied between studies (see Table 2). Two studies evaluated sustainability of the programme less than a year after initial delivery [ 35, 42], four took place one to two years later [ 33, 34, 37, 41], and four studies were conducted three to ten years after the initial implementation period [ 36, 38, 39, 40].

Five studies provided no definition of sustainability but referred only to activities being 'sustained' or 'maintained' at follow-up [ 34, 35, 38, 39, 42]. While several studies discussed prevailing implementation and sustainability theories or frameworks in their introductions, Dijkman et al. [ 41] and Loman et al. [ 36] were the only papers to develop a clear theoretical framework which was then used to guide research processes and analysis. For an overview of the different terms and frameworks used, see Table 2.

3.3. Study Design

Five studies were conducted using qualitative methods [ 33, 37, 39, 40, 42] and two of the included studies used solely quantitative data collection methods [ 36, 38]. Qualitative studies consisted of interviews with school staff, including teachers, headteachers, school clinicians, and psychologists. The remaining three studies used mixed methods, combining a checklist or questionnaire with qualitative interviews [ 34, 35, 41]. Table 3 outlines the study design and participants.

3.4. Quality Assessment

The quality of three of the qualitative studies was high, with rigorous data collection methods and coherent analysis and interpretation [ 33, 37, 39]. The quality of the remaining studies was lower. For the qualitative studies, this was mainly due to a lack of clarity in reporting of methods. Quantitative studies had issues with nonresponse bias, while mixed methods studies did not adequately integrate the qualitative and quantitative components of their design (see Table 3 for further details).

3.5. Synthesis of Barriers and Facilitators to Sustainability

For a list of the factors affecting sustainability that were discussed in each article see Table 4. The overarching factors, themes, and subthemes are described in detail below and the links between themes are portrayed visually in Figure 2.

Figure 2 is a visual representation of the various themes and subthemes outlined in Table 4. The arrows between the key sustainability factors identified here highlight the directional relationships between themes. For example, the theme around support and prioritisation of the intervention by school leaders (1) was linked to the allocation of resources (4), affecting the capacity of staff. Similarly, school culture, which was shaped by the school leadership (1), fed into staff engagement (2). The characteristics of a given intervention (3) affected the logistics and organisational effort (4) required for successful delivery, along with the engagement by individual staff members (2). Each theme is discussed in detail below, starting with the findings at the school level and then moving onto higher-level factors.

3.6. School Leadership

The influence of the school leadership team on the sustainability of an intervention was cited as a key factor in nearly all the papers included in this review. This factor is broken down into three themes below, with subthemes italicised in the text.

3.6.1. Support and Prioritisation

School leaders prioritising the intervention was identified as a key facilitator of sustainability, with teachers stating that leadership support was crucial to ensure that intervention activities would continue in the school timetable [ 33, 34, 38, 39, 41]. In contrast, conflicting priorities were found to be a barrier for some schools, where leadership teams were less actively involved and prioritised other tasks (often related to academic results) over the intervention [ 33, 37, 40, 41].

Strong leadership and communication around the intervention were found to facilitate sustained delivery, with successful leaders making clear decisions regarding the interventions and communicating priorities to staff [ 33, 34, 36, 40, 41]. However, lack of communication and the resulting lack of awareness among staff about the programme could be a barrier to implementation, particularly with an intervention such as 'First Step to Success'. This intervention involved teachers using a tool to identify students with high levels of anxiety and then referring them to school clinicians [ 36]. In this case, participants thought the lack of communication about what the intervention actually was and why it should be used may have led to insufficient numbers of referrals in the sustainability phase of their research [ 36].

3.6.2. School Culture, Values, and Policies

Promotion of a culture of support in a school from the senior leadership team was also discussed as a facilitator to sustaining programmes, along with a general willingness to try new things [ 33, 34, 37]. For some, this meant the school leaders being involved in the programme and being supportive of the philosophy: "school administrators make the decisions about what classes to offer so teachers mentioned administrator's support as crucial for ensuring the class could continue" [ 34] (p. 329). However, for others, support was more passive, with one school clinician saying that the senior staff were "very supportive of whatever I wanted to do. They didn't particularly get involved or ask questions, they just let me run it again" [ 37] (p. 137). This leadership support also led to increased motivation and commitment from staff [ 39].

Another way for school leaders to demonstrate support for the programme was to make the intervention part of school policy, cementing commitment to the intervention [ 40, 41]. In Dijkman et al.'s [ 41] study on the Good Behaviour Game (GBG), the GBG was mentioned in the policy plans of all the highly-sustained schools but in none of the weakly-sustained schools' policy plans.

3.6.3. Allocation of Resources

Having a designated programme lead was discussed both as a facilitator and a barrier to sustainability. A leadership-assigned programme coordinator or champion facilitated programme delivery by pushing for the programme to be implemented, promoting the programme, encouraging sustained use of the programme, and using relationships to overcome implementation barriers [ 33, 40, 41]. One of the participants in Dijkman et al.'s study highlighted this fundamental role as a coordinator for the Good Behaviour Game: "Honestly, I think that if it was not one of my tasks, the GBG would have just fallen over. No coordination - no GBG in the school" [ 41] (p. 86). However, the role of programme coordinator only worked if the individual staff member had enough allocated time to fulfil their responsibilities and stayed in the same role; champion staff turnover was identified as a barrier to continued delivery [ 33, 41].

School leaders were also important for sustainability through their provision of practical support, such as scheduling the intervention into the timetable, providing rooms for intervention delivery (e.g., a private office or a space for group activities) and access to computers and technical resources [ 33, 34, 35, 37, 39]. Allocating time for training was also identified as a facilitator, with teachers needing to be released from other duties to attend training sessions and some schools planning annual training for staff [ 33, 34, 36, 41].

3.7. Staff Engagement

Staff engagement in the delivery of interventions was the only factor discussed in every article in this review, with motivated staff contributing to the sustainability of interventions in some cases and a lack of engagement creating barriers for delivery in others. This factor is broken down into four themes below, with subthemes italicised in the text.

3.7.1. Commitment from Individuals

Sustainability was also facilitated by individual effort from staff members, with some teachers and school staff making adaptations in order to continue intervention delivery [ 33, 34, 37, 40, 41]. In Crane et al. [ 33], mental health staff set up peer consultation to troubleshoot difficulties, and in Friend et al. [ 34] teachers did not have time in their week to deliver 1:1 counselling meetings for pupils, but instead incorporated individual meetings into the class. Some clinicians in Nadeem and Ringle's [ 37] article also mentioned adapting the intervention resources slightly to engage the students more effectively (e.g., use of additional role plays or games). Similarly, in Dijkman et al.'s [ 41] study on GBG, the ability and willingness to take the initiative and make adaptations were found to be a key difference between the schools with weaker sustainability and those that sustained the GBG. Many schools perceived the intervention to be less suitable for children ≤6 years and ≥10 years, but in highly sustained schools the teachers worked with the GBG trainer to make adaptations, enabling the continuation of the intervention. In contrast, teachers in schools with weaker sustainability scores stopped using the programme completely when they encountered a problem [ 41]. With targeted interventions, it was also important for teachers to be involved in the process and take an active role in identifying and referring students [ 33, 34, 36].

School staff reported enjoying delivery of the interventions, stating that they were motivated to continue because the classes and sessions were fun to teach and in some cases made a pleasing change from normal lessons [ 34, 37, 38, 39]. Additionally, individual staff members also contributed to successful continuation by allowing time out of class for pupils to receive the interventions, and in some cases even walked the child to their intervention session [ 33]. Conversely, a lack of willingness for pupils to miss lessons was found to be a barrier to sustainability, with some teachers "protective" over students' time [ 33, 37].

3.7.2. Staff Turnover

Turnover of staff who were trained in intervention delivery was referenced as a key barrier to sustainability [ 33, 34, 36, 37, 39, 41]. In one instance, a successfully sustaining school had provided training for new members of staff to introduce them to the principles of the programme [ 40]. However, in most cases the lack of availability to send new members of staff on training greatly reduced the capacity of a school to deliver these mental health interventions. For some schools, staff turnover contributed to lower intervention fidelity, as teachers who had not received training or materials were delivering only parts of the intervention [ 34], while in other instances, the programme was completely discontinued [ 33, 36, 37].

3.7.3. Perceived Benefit for Pupils

Staff perceiving benefit for pupils was identified solely as a facilitator to sustainability. While some studies reported that school staff had seen the benefit of the intervention with regard to the mental health and wellbeing of the pupils [ 34, 37, 39], the most frequently reported benefit was pupil behaviour and classroom climate [ 34, 35, 37, 39, 41]. In Dijkman et al.'s [ 41] research, noticing results in terms of improved behaviour and a more positive classroom climate made teachers more willing to continue delivery. This study also referenced improved academic performance as an incentive for schools to continue delivering the intervention [ 41]. More general benefits for pupils were also referenced, with schools saying they had experienced a range of positive outcomes and benefits for their pupils, motivating staff to maintain intervention activities [ 35, 37, 38, 42]. This was highlighted in LoCurto et al.'s [ 38] quantitative study, where regression analyses were used to explore predictors of sustained use. Along with scales measuring the acceptability and difficulty of delivering the intervention, a statistically significant predictor was that clinicians with more positive beliefs that the intervention improved their students' outcomes were more likely to continue to use the treatment [ 38].

3.7.4. Pupil and Parent Engagement

Pupil engagement in the intervention was a facilitator to sustainability as staff were more likely to continue delivery when they thought pupils were enjoying and engaging in the sessions [ 33, 34, 35, 36, 37, 39]. In contrast, low levels of engagement were a barrier to sustainability. This was noted in Friend et al. [ 34], where low levels of pupil motivation were a barrier, and in Crane et al. [ 33], where some pupils' behavioural problems or the severity of their anxiety symptoms made it too difficult for them to engage in the programme.

Three studies referenced parent participation as an additional influence on sustainability; parent willingness to complete questionnaires and work with the school was a facilitator, but engaging parents for consent and treatment could also pose a challenge [ 33, 36, 37].

3.8. Intervention Characteristics

The different characteristics of each intervention were frequently cited in participants' discussions around sustainability; the content, training opportunities, intervention materials and resources were all found to influence schools' use of the intervention. This is broken down into three themes below, with additional subthemes italicised in the text.

3.8.1. Content and Design

The design of interventions was referenced in multiple studies, with the acceptability of interventions for staff highlighted as a facilitator to sustainability. Programme materials that were more acceptable and less difficult to implement were more likely to result in continued use [ 33, 37, 38, 39]. In LoCurto et al.'s [ 38] study, one of the strongest predictors was staff perceptions of the intervention materials: "clinicians who perceived the intervention materials as more acceptable, (i.e., easy to use, realistic/practical and fun to teach) and less difficult to implement, were more likely to report continued use" [ 38] (p. 686). Similarly, the practicality and ease of use of each intervention impacted sustainability. Interventions that were sustained were described as "easy to use/implement", "manageable" and "well organised" [ 33, 35, 38]. Conversely, some elements of interventions were not deemed to be practical, such as the lengthy screening tool in CCAL [ 33] and the time required out of class for pupils receiving CBITS [ 37]; these both created challenges for sustainability.

3.8.2. Quality of Materials and Training

The quality of intervention materials was cited as a facilitator to sustainability, with school staff noting the importance of ready-made sessions and professionally prepared resources [ 33, 37, 39]. Similarly, having sufficient training in intervention delivery was found to be a facilitator for some with school staff feeling confident and ready for delivery [ 34, 36, 39], and others suggesting more training was required [ 33].

3.8.3. Meeting Need and Fitting with School

The intervention meeting a need within a school influenced the likelihood that it would be sustained, with staff highlighting the ongoing need for the programme as a key facilitator [ 33, 34, 37, 41]. This was demonstrated in Dijkman et al.'s [ 41] research, where schools with high sustainability explained that the programme was needed to continue to solve behavioural problems in the school, whereas schools that were not sustaining the GBG felt this need was no longer there. This is highlighted by one of the participants in Dijkman et al.'s [ 41] study, who explained: "The most important reason for not doing it anymore is that the necessity is gone. A lot of teachers left and new teachers came. These new ones are another type of teacher, they don′t need it anymore" [ 41] (p. 85).

3.9. Resources

A barrier to sustainability mentioned in nearly all included articles was access to resources, both in relation to staff capacity and funding. This is broken down into two main themes below, and the subthemes are italicised in the text.

3.9.1. Staff Capacity

A frequent barrier to sustainability was staff having enough capacity to facilitate intervention delivery. Competing priorities and responsibilities for school staff often led to challenges, with some intervention activities going undelivered or being delivered with less consistency than during initial implementation [ 33, 34, 35, 37, 39, 41]. Examples of this include the cessation of lunchtime activities due to other staff responsibilities [ 34], and intervention coordinators being unable to provide adequate supervision for teachers [ 41]. In two articles, school clinicians reported having less time for direct therapy as a result of competing priorities such as administrative tasks, psychological testing, and crisis management [ 33, 37].

Class sizes and caseloads were also barriers to sustainability, with class sizes that were either too large or too small posing a challenge; large class sizes created difficulties with classroom management, but small groups were not sustainable as it was hard to justify offering the class [ 34]. Caseloads were also cited as a factor affecting sustainability; clinicians with smaller caseloads found it easier to continue the use of interventions, and higher caseloads were cited as one of the key reasons for stopping delivery [ 37, 38].

3.9.2. Funding

Lack of funding and appropriate resources were mentioned as barriers to delivering the interventions. If activities could be integrated easily into the school's usual provision or the specific duties of a staff member, lack of funding for an intervention posed less of a problem [ 41]. However, activities that required additional funds, such as hiring guest instructors to deliver sessions or paying for staff and parents to receive training, were not sustained [ 34, 36]. In the case of the total de-adoption of one intervention, a budget crisis at a higher level led to significant job restructuring and staff layoffs which resulted in the programme being cut [ 37].

3.10. External Support

While most of the included articles focused on sustainability at the school level, some higher-level factors were also discussed. The most salient factor was external support for interventions, which was found to be both a barrier in some instances and a facilitator in others. This factor is broken down into three themes below.

3.10.1. District Support

Two articles from the U.S. discussed district-level support (similar to local authority level in England) as an important facilitator for sustainability. Loman et al. [ 36] observed that most of the schools that sustained implementation of First Steps to Success adopted the programme as a part of a districtwide initiative, while the non-sustaining schools initiated the programme independently. District infrastructure, coordination, and leadership all contributed to the likelihood of a school continuing delivery of an intervention [ 36, 37].

3.10.2. Consistency and Shifting Priorities

While support at the district level could facilitate sustainability, this was found to be dependent on specific personnel, and schools reported district-level leadership changes as a barrier to continuing delivery. A participant in Nadeem and Ringle's [ 37] study explained that "without someone from the top supporting it and paving the way, it was very difficult to use [Cognitive Behavioural Intervention for Trauma in Schools] again" [ 37] (p. 138). With new leadership came shifting priorities; school clinicians reported that the focus had moved away from the programme, often onto academic success [ 37]. Similarly, Loman et al. [ 36] found that when key personnel moved from the district, the intervention quickly ceased to be implemented.

3.10.3. Higher-Level Support

One article mentioned that political endorsement of the prevention effort would be helpful, particularly when it came to school staff defending the intervention in front of colleagues [ 39].

4. Discussion

Given the increasing emphasis on schools to provide mental health education and support for children and young people, as well as significant local and national investment in this support, the aim of this research was to systematically review the factors affecting the sustainability of school-based mental health and emotional wellbeing programmes. The literature searches retrieved articles on both targeted and universal mental health interventions trialled in schools. These articles included a range of barriers and facilitators to sustained delivery. While some wider system-level factors were noted, most sustainability factors discussed in included articles were at school level, particularly in relation to school staff and leadership. Key facilitators to sustainability were leadership support and school staff members' perceived benefit of the intervention for pupils, while key barriers included staff turnover, capacity, and competing priorities.

Some themes were similar across both the school and wider system level-most notably, the importance of consistency and limited turnover of key personnel. Turnover amongst individual teachers (who had received intervention training), programme coordinators, the senior leadership team of a school, and even a district created a considerable barrier to sustainability. This is consistent with the broader literature on sustaining programmes in schools, where staffing issues are noted as one of the major barriers to sustainment [ 48, 49, 50]. Similarly, commitment and prioritisation across all levels of staff was a facilitator to sustained delivery of the mental health and wellbeing programmes in this review. This maps onto findings that identify continued engagement at all stakeholder levels as crucial [ 48, 50, 51]. For interventions to be sustained in schools, maintained commitment and prioritisation are required at all levels of the school system.

In addition, several barriers and facilitators identified here for mental health and wellbeing interventions are consistent with previous reviews. For example, Herlitz et al.'s [ 19] review on public health interventions in schools and Askell-Williams and Koh's [ 51] review on the sustainability of school initiatives both note the importance of school leadership support, staff turnover, perceived effectiveness, funding and resources, school policies and plans, belief in intervention, and fit with the school. This indicates that these themes may be central to sustainability irrespective of the nature of the intervention being implemented. However, there were some departures between the current review and those carried out previously. For instance, in both the Herlitz et al. [ 19] review and a recent qualitative study [ 48], a lack of confidence in school staff to deliver health promotion was a barrier to sustainability which did not feature in the current review. In contrast, while the importance of training was noted in the current review, there was a greater emphasis on staff enjoying delivering the sessions and simply having the capacity to do so. It is also perhaps surprising that the self-efficacy of staff which was highlighted in previous reviews did not come up in this review given the potentially sensitive content of these interventions. However, this may be due to schools' growing remit to provide programmes around mental health and wellbeing, or perhaps it is the result of a wider cultural shift towards openness and discussion on these topics in Western societies [ 52, 53].

The importance of evaluation and feedback around the intervention has also been cited as a key factor affecting sustainability in previous work [ 51], yet this was not observed here. In their development of a framework for sustainable implementation specifically relevant to educational contexts, Askell-Williams and Koh [ 51] highlight the need for such data collection but note that it often seems to be an afterthought. While the literature recommends the analysis of good quality implementation and sustainability data, the findings from the current review also show that this may be a gap as these data are not regularly collected by schools.

4.1. Strengths and Limitations

A strength of this review was that it used a broad definition of mental health and emotional wellbeing to capture a broad range of different types of school-based intervention, including both targeted and universal programmes. This allowed for a wide exploration of barriers and facilitators to sustainability in school settings pertaining to mental health and emotional wellbeing. This review included the rigorous double screening of titles, abstracts, and full texts (both with high kappa statistics) and the involvement of multiple researchers in thematic synthesis. This mitigates the risk of systematic bias at the screening stages whilst also decreasing the total number of errors or missed studies [ 54].

There are some limitations to this review. Despite attempts to conduct a comprehensive and broad search, with any systematic review there is a possibility that all relevant literature is not captured. This may be particularly relevant to sustainability as the construct is not well defined in the literature. To limit this, experts in the field were consulted and the reference sections of full-text articles were searched. However, it is possible that articles may have used a different synonym from those included in this search. In addition, the articles in this review have been limited to those published in English, excluding potentially relevant studies that may have been published in other languages.

To explore the sustainability of these interventions in schools, stringent criteria were employed regarding research being conducted after the initial implementation period when external support and funding had finished. As a consequence, some papers on the sustainability of mental health programmes in schools were not included in this review as their models either explicitly involved continued external support for schools, or it was not possible to discern what schools in the sample had received in terms of district-level support or funding (e.g., Arnold et al., 2021; McIntosh et al., 2016; and Pinkelman et al., 2015). In the research conducted by Ertesvåg et al. [ 40], school staff were interviewed both toward the end of the initial programme period and again two and half years later. However, in the results section of this paper, the authors do not distinguish between the two data collection timepoints. Therefore, it is not possible to ascertain which themes are specifically relevant to the research question of this review. In order not to omit potentially relevant information for this review, Ertesvåg et al.'s [ 40] findings were included in the thematic analysis, and the barriers and facilitators identified were included in the discussion of the results, whilst also noted in grey at the end of Table 4.

4.2. Recommendations

While not included in this review, models involving continued external support for schools may be an important pathway for sustained delivery of mental health interventions, and this should be explored further. The issue of staff turnover and shifting priorities at all levels of school systems is also an important area of focus, particularly as sustainment seems to be driven forward by individual members of school staff with little or no consideration of a wider network of responsibility and support. Crane et al. [ 33] set out to interview members of school staff at three timepoints but encountered low response rates at Year 3 due to staff turnover and participant attrition. In this instance, staff turnover proved to be a barrier to the research as well as to sustaining the intervention.

The articles in this review all pertain to schools in high-income countries where greater resources and capacity are available. With evidence of effective school-based mental health interventions also being delivered in low-income and middle-income countries, research into sustainability in different settings is crucial [ 55].

In keeping with Wiltsey-Stirman et al.'s [ 18] review on the sustainability of interventions, over half of the included studies did not include definitions of sustainability. Future studies should define sustainability and draw on implementation and sustainability frameworks to shape their research. For example, it would also be useful to underpin future research with a framework such as the Theoretical Domains Framework, which draws on behaviour change theories [ 56]. This framework approach could allow for further understanding of factors that may improve the implementation and sustainability of these interventions and assist with the development of practical solutions to some of the challenges.

In this review, we found that the perceived benefit of the interventions by school staff was a facilitator to sustainability, but it was not possible to draw conclusions about a link between effectiveness data regarding the interventions and sustained use. As in Herlitz et al.'s [ 19] review, there were gaps in reporting evidence of effectiveness and sustainability. This is a key question for future research and must be considered carefully when designing intervention trials.

Although a number of studies evaluated interventions at two timepoints (initial implementation and sustainability), only one of the research designs included here explored the process of sustainability over multiple timepoints [ 37]. This highlights a gap in understanding sustainability not only as an outcome (where activities are maintained) but also as a complex process involving adaptation and development in response to the emerging needs of a given system [ 57]. To explore sustainability as a process, future research would benefit from stronger designs and methodology, particularly longitudinal research involving multiple timepoints.

5. Conclusions

There is little high-quality research on the sustainability of mental health and emotional wellbeing interventions in schools. Although there are promising findings on the effectiveness of some school-based interventions for mental health [ 9], research on long-term implementation and sustainability is very limited. Despite this, a range of barriers and facilitators to sustaining these types of intervention in schools have been identified in this review. The majority of these barriers and facilitators to mental health interventions are at the school level and are very similar to health interventions and educational improvement interventions more generally [ 19, 51]. Given this, it is important for sustainability researchers to focus broadly on the difficulties of delivering interventions in school settings and the unique challenges of working within such complex systems [ 58, 59]. Barriers such as constantly shifting priorities and high levels of staff turnover may be particularly salient in schools and consequently would require specific approaches to increase sustainability.

In the U.K., there has been a significant policy shift communicating that pupils' mental health and emotional wellbeing falls at least partly in schools' remit. This has paved the way for greater infrastructure to provide mental health support in schools. It is yet to be established whether these changes might remove some of the barriers described in this review and improve the capacity of schools to sustain these types of interventions. While interventions becoming part of school culture and values may facilitate sustainability, the ever-pressing concerns around logistics, limited time, and capacity in schools suggest that more is required from leaders and policymakers for mental health and wellbeing interventions to be successfully sustained.

Supplementary Materials

Author Contributions

A.M., J.D., E.S. and D.H. conceptualized the study and developed the design and methodology. A.M. and R.T. conducted the literature screening and A.M. conducted the data synthesis with support from E.S., J.D. and D.H. A.M. prepared the original draft and J.D., E.S., D.H. and R.T. assisted with reviewing and editing the paper. All authors have read and agreed to the published version of the manuscript.

Funding

This work is funded by the Department for Education and the Evidence Based Practice Unit (UCL and Anna Freud Centre). RT is funded by the National Institute for Health Research ARC North Thames. The views expressed in this report are those of the author(s) and not necessarily those of the Department for Education, National Institute for Health Research or the Department of Health and Social Care.

Institutional Review Board Statement

Informed Consent Statement

Data Availability Statement

Conflicts of Interest

The authors declare no conflict of interest.

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Barriers and Facilitators to Sustaining School-Based Mental Health and Wellbeing Interventions: A Systematic Review

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Despite an increasing focus on schools to deliver support and education around mental health and wellbeing, interventions are often not sustained beyond initial funding and research. In this review, the barriers and facilitators to sustaining mental health and wellbeing interventions in schools are explored.

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School Mental Health Workforce Recruitment and Retention

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School Mental Health Workforce Recruitment and Retention

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School Mental Health Workforce Recruitment and Retention

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School Mental Health Workforce Recruitment and Retention

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School Mental Health Workforce Recruitment and Retention The following resources offer information about recruitment and retention of SMH providers, innovative strategies, policy adaptation, and other key considerations for the SMH workforce. Check out the links below for more information. Why is the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Medicaid Benefit Underutilized in Financing School-based Mental Health Services?

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Students and School Based Mental Health Services

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About 1 in 4 teachers said they were experiencing symptoms of depression in an early 2021 survey by the RAND Corp., a research group and think tank. In a separate survey, RAND also found that most secondary school principals were experiencing frequent job-related stress -and one of their big stressors was supporting teachers' mental health and well-being.

Left unaddressed, that stress could lead to a massive exodus of educators. Despite that, only a third of district and school leaders said they have made counselors or mental health services available to staff since the start of the pandemic or added to the mental health services already offered, according to a nationally representative EdWeek Research Center survey of nearly 900 educators conducted in January and February.

Forty-four percent of those who responded said they have offered or increased their offerings of professional development on self-care, which educators and experts say is not enough on its own to address clinical mental health needs. And 17 percent said they have not taken any steps to address staff mental health needs during the pandemic even though their current offerings are inadequate.

Targeted mental health support for staff is crucial for a thriving school environment, experts say.

"Teacher well-being is incredibly important, not only for them but for their students' learning experiences as well," said Leigh McLean, an assistant research professor at the Center for Research in Education & Social Policy at the University of Delaware.

Her research has found that teachers with depression spend less time doing whole-class instruction -likely because it's more demanding and energy-intensive-and have fewer warm and responsive interactions with students. They also spend less time planning and organizing their lessons.

Having structural supports for teacher mental health will ultimately benefit everyone in the school building, including school leaders. If teachers and students have access to counseling and other mental health support, that's a heavy burden taken off their principals' backs.

Building a culture of support

McLean's research has found that teachers' mental health and commitment to their career is better protected when they experience more support and autonomy from school leaders. Having colleagues whom teachers can turn to for help also boosts mental health, she said.

In preliminary research, McLean found that during the pandemic, certain teachers are struggling with their mental health more than others: teachers of color, early-career teachers, and those in high-needs schools.

Ronn Nozoe, the chief executive officer of the National Association of Secondary School Principals, has advocated for districts and schools to use some of their federal COVID-19 relief funds to set up targeted support programs for school leaders' mental health.

However, there's a huge demand for mental health care professionals nationally, and school districts may be competing with others with deeper pockets.

Additionally, Nozoe said, even school leaders who know the importance of mental health care are more willing to spend available funds on students and teachers than themselves. And there's still a stigma around mental health, he said.

"It's not for lack of want, it's not for lack of ideas," Nozoe said. "It's really a lack of available professionals who are willing and qualified to provide these kinds of services to help kids and families and ultimately educators."

How can school leaders best respond to these pressures? One way is to take stock of their resources, make workers aware of them, and ensure they're available.

In May, the Colorado School of Public Health's Center for Health, Work, & Environment partnered with the University of Colorado's Depression Center to launch a workplace mental health module -an online tool kit for employers to take stock of the management and workplace strategies they have in place to address the mental health of their staff. Employers take a survey that assesses their workplace culture, employee benefits, education and training, and equity and accessibility.

The module is open to all employers in the country, including schools. So far, five districts in Colorado have signed on, including the Denver public schools, said David Shapiro, the program manager for Health Links at CHWE, which distributes the module. These districts typically score high on employee benefits for mental health, he said, but there was a need for more education and training.

For example, all school employees should learn how to access available supports for their own mental health needs. And schools should establish peer-support programs, so some employees learn "how to be an ally or 'askable' adult for their colleague to get the support they need," Shapiro said. He recommends that districts train certain teachers or other staff members so there are "champions for mental health within the school district" who aren't in leadership positions. (After all, it can be intimidating to confide in your boss, Shapiro noted.)

Also, school and district leaders should make sure they're sharing information about mental health benefits in an equitable way, he said. Some school staffers, like bus drivers, might not check their emails as frequently as teachers-so principals should consider delivering the information through nonelectronic methods, like posters or mailers, too. Also, the information should be available in multiple languages.

And school leaders must create a workplace culture where people can be open about mental health, he said.

It's important to have "people be willing to share their stories, and I think this starts with leaders," Shapiro said. "[They can tell staff], 'This pandemic has been challenging for my own mental health-here's how it impacted me, and I've used my mental health benefits [to get help]'. The more we can build the story of mental health, the more we can spread awareness, the more we can reduce stigma."

Partnerships to Uplift Communities Schools, or PUC Schools, which serves students in northeast Los Angeles and the San Fernando Valley in California, has counseling sessions available for students, teachers, and principals. Max Valadez, the principal of PUC Lakeview Charter Academy, said those sessions have helped him navigate challenges in his personal life and served him in his role as a school leader.

"As a principal, there are so many moving pieces, sometimes I just need to talk to somebody who is not going to judge or anything like that-just to let me know if I am doing things correctly or if I'm not," Valadez said.

Modeling and demonstrating concern for mental health

When Sarah Broome was the executive director of Thrive Academy, a statewide public boarding school in Baton Rouge, La., everybody on staff knew when her weekly therapy appointment was because she spoke about it so freely. Broome, who resigned as the executive director in June 2021 and is now an education consultant, said that openness about mental health helped lessen any stigma for other adults in the building to get help.

When students returned to campus in August 2020 after the initial coronavirus shutdowns, Paul Sampson, Thrive's principal at the time, and Chelsea Trice, the school's head social worker, decided that it wasn't enough to prioritize students' mental health-they needed to offer robust support to educators, too. Broome agreed.

"We are not a place that cares about mental health unless we care about mental health for everybody, and that includes our adults on campus," Broome said. "Teaching was really hard before the pandemic, and it's only gotten exponentially more so. Teachers need places to process [their feelings]."

The school began offering teachers the option to participate in individual therapy sessions with school social workers every other week. (Thrive later hired contract social workers, in case teachers felt more comfortable talking with someone who wasn't on staff.) The social workers kept all information shared during the sessions confidential but also compiled top-level trends and shared that data with administrators.

Moreover, the school held weekly group therapy meetings where teachers could talk about specific student academic and social-emotional needs and discuss the best strategies to take. The meetings allowed administrators to hear teachers' concerns and address them immediately, Broome said.

But none of this work was an overnight fix, she said. And teachers were able to go to these therapy sessions because school leadership had built significant amounts of teacher planning time into the schedule.

"You can't mental-health-support your way out of structural challenges," Broome said. "There is literally nothing you can do for a teacher who is not able to go to the bathroom all day."

Valadez, the Lakeview Charter Academy principal, has also been trying to find ways to reduce the strain on his teachers, especially those who've had to fill in for colleagues who're absent because of COVID-19.

A few nonteaching staff members have recently obtained their teacher-substitute permits, and the charter school network also contracted with a substitute company, which allows the school to have a substitute ready if a teacher gives two weeks' notice that he or she will be absent. Both changes reduce the frequency teachers will be called upon to fill in for peers-eliminating a huge stressor.

Outside resources and partnerships can help

The PUC charter schools network relies heavily on graduate interns studying American family therapy-a cheaper way to staff counseling programs for students and educators, since the interns are not paid and are getting experience and credit toward their degrees.

That program was started in the early 2000s and is run by Christine Sartiaguda, a licensed marital and family therapist who also has a doctorate in education. It has grown from Sartiaguda and 16 interns to include 50 to 60 clinical interns annually, working under a team of five licensed clinical supervisors. While the program was initially geared to support students, teachers and school leaders were always able to tap into it. But the outreach to teachers and principals became more systematic since the pandemic.

"With COVID, we realized that it wasn't a matter of waiting for the teachers to ask, it was about us being proactive-recognizing and just seeing the impact COVID has had on teachers trying to pivot to online learning," she said. "They look tired, they look stressed, and we just need to provide the support and hope they take advantage of it."

Just one month after the initial shutdown in spring 2020, Sartiaguda started offering teacher-support groups via Zoom. By fall of the 2020-21 school year, those groups were available at all the network's campuses. Staff meetings include meditation and mindfulness exercises. Professional development has self-care for teachers-"simple, simple ways that they can fit in one minute of mindfulness in their day, just to kind of disconnect from the chaos of having to practice and teach," she said.

Sartiaguda's staff can tailor supports to meet individual schools' needs.

"If a [school] leader comes to us and says, 'I've had a lot of my teachers who've experienced deaths in their families since COVID began, can you do a specific group just addressing grief and loss?,' the answer is yes," she said. "Whatever the need is, we can accommodate it."

Because the interns are receiving their degrees in marital and family therapy, their primary focus in schools remains getting experience in those areas.

"But we have really restructured our program to include the teacher piece," Sartiaguda said. In addition, her team provides referrals to low-cost counselors and therapists in the community.

Getting buy-in from educators

Although teachers are stressed, not all are taking advantage of the mental health resources the PUC network is offering, Sartiaguda said.

After the end of a long day, some teachers did not want to log on to Zoom for another hour-even if they knew the benefits, she said.

"We do try sometimes to offer it during lunchtime, and sometimes teachers say, 'You know what. I just want to eat my lunch [or] I need to prep.'" But she added, "what we emphasize is, it is here if you change your mind. If you reach a point of, 'Well, I actually want to make time for this support,' it is absolutely available."

Valadez, who became the principal of PUC Lakeview Charter Academy just a few months before the pandemic, said about 20 percent of the school's teachers have taken advantage of the on-site counselors over the last two years. Some needed help with family issues such as deaths in the family and anxiety related to a child heading off to college amid a pandemic.

Valadez knows that some teachers may be uncomfortable speaking with him and the assistant principal about professional and personal problems, so he always lets them know that "there's somebody else they can talk to."

Jennifer Lopez, a teacher at PUC Community Charter Elementary School in Los Angeles, started a self-care committee shortly after the shutdown in March 2020, with the support of Principal Jocelyn Velez, to help teachers focus on their well-being, develop coping skills, and provide other support, amid the pandemic.

Both say the committee will become a permanent part of the school going forward.

"One of the teachers said, 'This is the one meeting I can miss but the one meeting I don't want to miss because I need this type of support,' " Velez said. "That's always really nice to hear."

The topics Lopez tackles during the meetings, which initially were held over Zoom, come from teacher surveys and feedback. She's also organized book studies on wellbeing and hosted sessions on yoga and financial wellness.

Now back on campus, the group continues to meet weekly. Administrators have also joined in, including on a recent nature walk.

"It's been really cool to bring that community back to campus," Lopez said. "It's been really awesome to have our admin support and [have] them thinking of ways for us to take care of our mental health."

Weekly emails go beyond self-help pick-me-ups, Velez said, and provide concrete tips and techniques that teachers can use to weather this traumatic period.

This semester, the group is studying Tina Boogren's 180 Days of Self-Care for Busy Educators, a guide to helping educators find the right balance.

Lopez recently hosted a "vision board" activity to help staff members visualize both their professional and personal intentions.

"It was nice to take that time in our busy lives to sit down, cut out pictures, and print out pictures, and sit down with our staff members, and talk about our goals in a very genuine way," said Velez. "In a time of chaos, ... allowing ourselves to be ourselves, bringing that person behind the professional into the classrooms with a group of teachers-that was very impactful, I think."

Principals can create an environment in which teachers know they can go to their bosses and say they need to take a break, Velez said. She has been encouraging teachers to take the day off when they need to and she's been modeling that behavior to staff.

"We have a trusting relationship at our school and we've built that culture-it's taken some time, but it's that trust," Velez said.

For example, a teacher, who is pregnant, recently texted Velez one night saying that her feet were swollen.

Velez responded, "You can take the day off tomorrow," she said. "I would just need to know so I can get a sub. But we want you to be healthy, we want you to take care of yourself. We want you to follow the doctor's orders. So, if it means extra rest-take the day off.

"It's really letting them know it's going to be OK," she said. "I just want you to take care of yourself."

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Don't Forget the Adults: How Schools and Districts Can Support Educator Mental Health

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The pandemic's mental health toll on teachers, principals, and school staff demands redoubled attention to resources and support.

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In this podcast, we talk with school administrators, educators, clinicians, and parents to open a dialogue that will help the growing number of students struggling with mental illness.

In this podcast, we talk with school administrators, educators, clinicians, and parents to open a dialogue that will help the growing number of students struggling with mental illness.

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conversations about student mental health

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‎Conversations About Student Mental Health on Apple Podcasts

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In this podcast, we talk with school administrators, educators, clinicians, and parents to open a dialogue that will help the growing number of students struggling with mental illness.

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Principal Matters | William D. Parker & Friends

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Helen Kelly is an author, speaker, consultant, coach and researcher in the field of school wellbeing and culture. She was a principal in international schools in Asia and Europe for 15 years and has been conducting research in the field of principal and teacher wellbeing for almost a decade. Prior to becoming a teacher, she spent ten years as a lawyer in the field of workplace health and safety.

From this diverse experience, Helen brings a unique and valuable perspective to her writing, workshops and consulting. She works with schools around the world, in both the public and private sectors, to help them to maximize staff wellbeing and improve workplace culture. She also works with leadership teams and individual leaders to help them to make their leadership more sustainable.

She is the author of the new book School Leaders Matter: Preventing Burnout, Managing Stress and Improving Wellbeing, published by Routledge. Helen is from the UK but is in the process of moving to the west coast of Ireland.

Can you fill in the blanks on that introduction and tell listeners something else they may be surprised to know about you?

I experienced a burnout in 2019 and had to cut my career in education short.

You spent a career practicing law before becoming an educator, and you've served in international settings. How has your time in different career paths provided you a perspective that may be helpful for school leaders to consider in their own practice?

Having worked as a lawyer in the field of workplace health and safety, I have an understanding of how we should be treating stress as a health and safety risk in the same way as other risks. Working in international schools really helped me to understand the emotional demands of the principal's role. You are responsible for all these people, staff, students and parents who are living away from their support networks. The emotional demands are huge. We talk so much about workload in relation to the amount of work we have to do as leaders but if governments, schools and leaders are to support leader wellbeing effectively, they need to acknowledge, understand and take steps to support emotional and psychological health.

Your new book focuses on several areas concerning the stress and workloads of school leaders. What causes burnout, how can people recognize it and how can it be prevented?

Understand burnout as a continuum.

3 dimensions

6 areas of worklife

Book contains details on signs and symptoms of each of the 3 dimensions

What advice do you have for educators for providing a framework to support thriving and resilience?

For individual educators it is about understanding 2 things, your work demands and your work recovery.

Identify areas of mismatch in 6 areas of worklife and take steps to address the imbalance

Understand their work recovery - 4 areas and 4 periods when we can be experiencing this

What practical coping strategies do you use or suggest for leaders who are feeling overwhelmed?

Get your work recovery in place. Sleep. Look for social support - coaching, supervision, networking, mentoring.

What parting words or advice would you have for leaders and how can they stay connected with your work?

Your wellbeing matters to the whole community. Schools and leaders need to start taking strategic approaches to improve working conditions for leaders but we also need to start seeing self-care as a core leadership attribute - an investment in the whole school community, rather than being embarrassed about it.

You can connect with Dr. Helen Kelly at Dr.HelenKelly.com

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PMP337: Helping Leaders Improve Wellbeing with Dr. Helen Kelly | Principal Matters

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Abstract

This paper reviews the evidence base supporting early detection of depression through school-based screening. An overview of the rationale for school-based depression screening is presented. Evaluation highlights from established screening programs based in secondary schools that have been reviewed in the mental health, public health, and educational literatures are described. Presented in greater detail is the University of Washington's Developmental Pathways Screening Program including a summary of research findings that have supported its development and implementation.

Adolescent depression constitutes a major public health problem. By age 18, an estimated 20% of the U.S. population experiences an episode of major depression, and as many as 65% of adolescents report depressive symptoms ( Kessler et al., 1994; Lewinsohn et al., 1993). For adolescents depressive episodes typically last 7-9 months, and 5-year recurrence rates approach 70% ( Lewinsohn et al., 1995; McCauley et al., 1993; Rao et al., 1995). Depression is associated with adverse outcomes, including poor school performance, substance use problems, and suicide ( Armstrong & Costello, 1999; Fergusson & Woodward, 2002; Glied & Pine, 2002; Rao et al., 1995; Rohde, Lewinsohn, & Seeley, 1996; Vander Steop et al., 2000). The World Health Organization has cited depression as the leading cause of disability worldwide and as the fourth leading contributor to the global burden of disease ( World Health Organization [WHO], 1996, 2004).

Intervention with adolescents experiencing subclinical signs of depression can significantly reduce depressive symptoms and the incidence of depressive disorders ( Clarke et al., 2001; Gillham et al., 1995; Jaycox et al., 1994; Horowitz & Garber, 2006; Garber et al., 2009). For adolescents already experiencing depression, early identification and appropriate intervention can result in relief from depressive symptoms, a reduced number of recurrences, and improvement in academic performance ( Allgood-Merten, Lewinsohn, & Hops, 1990; Brent et al., 1997; Garber & McCauley, 2002; Garber, 2006; Kahn et al., 1990; Kazdin & Weisz, 1998; Lewinsohn & Clarke, 1999; Shochet et al., 2001). Longitudinal research indicates that obtaining treatment for adolescent depression leads to a significant reduction in the risk of depression during adulthood ( Feehan et al., 1993; Harrington et al., 1996). This reduced risk for long-term adverse outcomes underscores the necessity for early identification. However, depression is more challenging to detect than externalizing conditions such as attention deficit hyperactivity disorder, oppositional defiant disorder, or conduct disorder.

This paper reviews the evidence base that supports early detection of depression through school-based screening. An overview of the rationale for school-based depression screening is presented as well as evaluation highlights from established programs based in secondary schools that have been reviewed in the mental health, public health, and educational literatures. Described in greater detail are the University of Washington's Developmental Pathways Screening Program and the growing evidence base that supports its development and implementation.

Addressing Depression from a Public Health Perspective

Studies suggest that only one-fourth to one-third of depressed adolescents receive treatment ( Mills et al., 2006; Weist et al., 2007; Zuckerbrot et al., 2007). Among those who seek treatment, access is not equally distributed. Indeed, factors such as race, ethnicity, language, culture, age, gender, financial status, and insurance status affect service utilization ( Cassano & Fava, 2002), with historically marginalized and stigmatized populations having the least access to necessary services (Mills et al.). In 2003, the New Freedom Commission reported the discrepancy between recognized mental health needs and the receipt of necessary mental health services ( Center for Disease Control [CDC], 2003). The failure of the national mental health system to address the emotional health needs of our youth heightens the necessity for alternative solutions. A promising early intervention is found in the public health arsenal: screening. Screening interventions that detect early signs of depression implemented in conjunction with programs that provide support to those who screen positive have the potential to halt disease progression and reduce the long-term negative outcomes associated with early onset of the disease ( Cole, Luby, & Sullivan, 2008).

Early Detection and Prevention in Secondary Schools

Schools serve as an ideal setting for the early detection of emotional disorders. The public school system touches the lives of most American children, especially those from historically disadvantaged and vulnerable populations. Because of their broad reach, school-based mental health (SBMH) programs can access youth who are typically missed by interventions that are only available in the health care sector ( Cuijpers, van Straten, Smits, & Smit, 2006; Mills et al., 2006; Vander Stoep et al., 2005; Weist et al., 2007). Schools have begun to extend mental health services to students as part of coordinated school health programs (SBMH) (Weist et al.). SBMH programs reduce barriers to learning, increase contact with students, and expand the scope of engagement strategies addressing educational, emotional, behavioral, and developmental needs (Weist et al.). Research describes the shift from clinic-based to school-based mental health interventions, asserting that 70-80% of school-age children who receive mental health services access them through their schools ( Chatterji et al., 2004).

Parents, teachers, and school counselors can readily identify some forms of emotional distress, especially those that manifest as disruptive behavior problems. However, the "quieter" forms of distress that manifest their effects on thoughts and feelings, rather than behavior often go unrecognized in children and adolescents until serious manifestations, such as suicidal ideation or behavior are evident. Systematic assessments that target internalizing symptomology can assist in identifying at-risk students ( Cole et al., 2008; Mills et al., 2006; Zuckerbrot et al., 2007). Because children may be reticent to reveal their negative cognitions and emotions and report potentially stigmatizing information in face-to-face evaluations, researchers have developed and validated self-report screening tools to tap childhood internalizing symptoms ( Scott et al., 2009). These tools accurately differentiate distressed from non-distressed children and can be administered confidentially in group settings.

Support for screening is founded on the belief that mental illness has identifiable traits and is highly treatable when identified ( Gould et al., 2005). For a screening program to be worthwhile, it should be capable of identifying cases in early clinical stages, and it should lead to the application of effective intervention during this preclinical phase. If both of these criteria are met, the screening program will be effective in halting disease progression ( Hennekens & Buring, 1987). Completing a depression screen presents low risk to students but has the potential to yield high benefits in terms of morbidity, disability and mortality reduction ( Kent, Vostanis, & Feehan, 1997; Weist et al., 2007).

Children routinely receive physical check-ups that include examination for illnesses, such as scoliosis with a low prevalence. However, children rarely receive emotional health check-ups, despite the high prevalence estimates of child and adolescent mental illness. The New Freedom Committee and the Child Mental Health Screening and Prevention Act, with the support of the Garrett Lee Smith Memorial Act, stimulated some attention and funding to screening for mental illness ( Friedman, 2006; Gould et al., 2005). As a result, screening programs have cropped up in schools across the country. Described below are four different secondary school-based depression screening models. is a schematic depicting the differing levels of concern and intervention that are intrinsic to the screening models.

Reynolds' Multi-stage Depression Screening

Because of the episodic nature of depressive illness and often transient nature of depressive symptoms, Reynolds (1986) introduced a multiple-stage screening model. The multiple assessment model addresses the potential of having a high number of false positives in initial screens. In this model, the first round of screening is universal. The second round is a rescreening of those who screened high the first time, roughly 3-6 weeks after original assessment. The third and final round is a clinical evaluation of all the students who screened high in the second round. At no point in the process were the screens intended to function as formal diagnosis of depression. Rather, the program sought to identify those at risk of depression and those in need of intervention. Although this program was described in the scientific literature, no evaluation reports have been published. Recent school-based models, in particular Teen Screen and Signs of Suicide (SOS), have built on and modified Reynolds' early screening model.

TeenScreen

Columbia University's TeenScreen Program is a voluntary mental health check-up program that assists both students and parents in understanding the changes of adolescence. Since its inception, the program has spread from its original location in New York City to over 500 local sites (schools and community-based settings) in 43 states and Washington, D.C. TeenScreen's program, which assesses children age 9-18, consists of two parts: administration of a questionnaire that takes 10 minutes to complete and assesses depressive symptoms, suicidal ideation and attempts, anxiety, substance use, and general health problems and follow-up of positive screens by a mental health professional. The follow-up interview functions as a verification process, to confirm whether the questionnaire's result is clinically significant. If deemed necessary, students and parents are offered free referrals for further evaluation. In 2005, the program screened roughly 55,000 students across the U.S. 33% of TeenScreen participants screened positive, and 17% positive screens required further evaluation ( Friedman, 2006). Recently, Scott et al. (2009) evaluated the effectiveness of the TeenScreen Program. In that study, the research staff tested TeenScreen's effectiveness at identifying distressed students. Although TeenScreen aims to identify students at risk, its effort would be redundant if the program only identified students already recognized as at-risk by school officials. The research staff recruited study participants from seven high schools in the New York City metropolitan area. In total, 1729 students participated in the screening, and 489 students screened positive. The principal nominated staff to serve as identifiers of troubled youth, and each staff member was blinded to the student's screen status. Staff members were asked to assess level of concern about each student's emotional health. Ultimately, the research staff determined that roughly 34% of students who had screened positive with TeenScreen were not identified as at-risk by faculty. These findings support the idea that screening captures manifestations of adolescent distress that are otherwise overlooked by involved adults. ( Scott et al., 2009).

Signs of Suicide

Signs of Suicide (SOS) is a school-based prevention program that includes both an educational and a screening element. The SOS program includes a short curriculum to increase awareness of suicide and the risks leading to suicide. A unique feature of this education component is the emphasis on peer intervention. The program outlines a response plan entitled ACT that stands for Ask, Care, and Tell. When they suspect a peer is suicidal, students are instructed to ask how the peer how s/he is doing, to remind the peer that they care and to tell their concerns about the student to an adult. According to developmental theory, peers serve as the primary sphere of social involvement during adolescence; therefore, SOS's peer focused intervention appears developmentally appropriate for this age group ( Aseltine & DeMartino, 2004). The screening portion of this project varies from TeenScreen's model. In the SOS program, students voluntarily complete a screening questionnaire that taps depressive symptoms and suicidal thoughts; then students are responsible for scoring their own questionnaires. SOS program staff informs students of what constitutes a positive screen, and the onus to follow-up with appropriate services is on the students. In an outcome evaluation conducted by Aseltine and DeMartino (2004), SOS demonstrated a short-term impact on students' attitudes and behavior towards suicide. In the study, 2100 students in five schools (3 in Hartford, CT and 2 in Columbus, GA) participated in a randomized control study. These students represented a racially and economically diverse sample. Students in the intervention group were administered the 2-day SOS program in either health or social studies class. Students in the control group were not exposed to the SOS program until the evaluation was complete. Three months after implementation of this program to the intervention group, the entire study sample was surveyed about their attitudes and behaviors in terms of suicide. The results of this assessment illustrated that the intervention group maintained lower rates of suicide attempts, greater knowledge about suicide prevention as well as a nuanced attitude about depression and suicide. Evaluation of the long-term effects of this program has not been conducted (Ibid).

As evidenced above, a number of program models incorporating mental health screening in school settings have been implemented and evaluated. Two extend the reach of early identification by making straight forward screening approaches available within the school setting and providing resources for (TeenScreen) or encouragement of (SOS) a follow-up response to a positive screen. None of the models coupled the multiple-stage screening model with a systematic on-site follow-up that actively facilitates student linkage to supportive services.

Developmental Pathways Screening Program

The Developmental Pathways Screening Program (DPSP) was designed to identify students experiencing emotional distress as they transition to middle school, to determine the source of their distress, and to link these students to supports to enhance their chances for a healthy, successful start to middle school. The program targets a developmental transition from elementary school to middle school, a time of vulnerability that can adversely affect a child's self-esteem, social engagement, and scholastic performance. DPSP identifies students early in the transition period when the risk of emotional distress is heightened and when even those with distress levels below diagnostic thresholds face adverse long-term outcomes, if their distress is not addressed. The screening program is implemented universally, as some manifestations of distress remain invisible and thus are frequently overlooked. Child mental health professionals visit schools to conduct follow-up evaluations of students who screen positive. Need for support is determined and linkages to school and community-based academic, social, and mental health supports are facilitated.

Theoretical Model Underlying DPSP

DPSP retains important components of prior mental health screening models. Firstly, the project is implemented in the school setting. All participating students initially complete a brief, valid confidential screening questionnaire assessing their depressive and conduct problem symptoms. Child mental health professionals provide on-site follow-up evaluations for positive screens and contact parents of all students who undergo evaluation to deliver recommendations for support. The model extends previous screening models in several important ways. DPSP targets children prior to the high school years when a precipitous increase is observed in the incidence of depressive disorders. Because the normative transition to middle school is stressful to most students and can trigger previously latent emotional distress in vulnerable students, the initial round of screening is universal in nature. In the middle phase of program implementation, students are considered positive screens if they show early signs of distress, scoring below a cut off score threshold that is set below the clinical range established for the screening measures. Child mental health professionals (CMHP) offer on-site follow-up evaluation to all positive screens. During and after this evaluation, the CMHP facilitates the student's connection to appropriate academic, social and mental health services by using motivational interviewing techniques in conversations with students and their caregivers. DPSP seeks to shorten the typical 6-8 year delay between the onset of a mood disorder and treatment seeking ( Friedman, 2006) and to improve 6 th graders' adjustment to middle school through early identification of distress as well as active linkage with appropriate services. describes some of the specific features of the DPSP screening program.

Evaluation of the DPSP

Over the years, a series of evaluations of the Developmental Pathways Screening Program have been carried out to address questions of whether:

implementation of school-based mental health screening was feasible,

screening was acceptable to families from a variety of racial and ethnic backgrounds,

the DPSP was cost effective,

active or passive parental consent matters,

screening generated an unacceptable number of false positives,

linkages to needed supports were successfully facilitated, and

the DSPS screening model was associated with a better school adjustment, linkage to supports, and parent satisfaction than a streamlined screening model.

Evaluation study methods and results are summarized below.

Feasibility

Initially, our concern was whether we could successfully inform families about the program and encourage them to participate, implement confidential screening in classrooms, and finally train and deploy part time clinicians to conduct onsite follow-ups. The DPSP was initially implemented in 2002 in four Seattle area middle schools ( Vander Stoep et al., 2005) as part of a NIMH-funded epidemiological study of children's mental health. A total of 861 6 th grade students, or 81% of enrollees at the four schools participated. Of the participating students, 15% screened positive and received an onsite structured follow-up assessment with a child mental health professional. Out of these students, 59% were determined to need additional support, including academic tutoring, referral to the school counselor, or community mental health services. Successful implementation of in-class screening was facilitated by strong collaborative relationships between DPSP and school staff. Confidentiality was maintained. High participation in 2002 screening was due in part to conditions of "passive" parental consent.

Acceptability

Public school systems in urban areas of the U.S. serve diverse populations. In the Seattle Public Schools, 23% of students are African American, 23% are Asian American, and 11% are of Hispanic origin. Thirty-nine percent meet eligibility requirements to receive free or reduced price lunches. A high percentage of students have at least one immigrant parent. Foundation funding obtained in 2004 was used to focus on questions of racial and ethnic differences in DSPS participation and outcomes. Parents were telephoned six weeks after screening and follow-up to collect information on three areas: linkage, barriers to linkage, and program satisfaction. Racial differences in participation rates were noted, with 49% African American, and 51% of Asian American students screened, compared to 67% of Hispanic, and 71% of European American students. No racial/ethnic differences were found in the percentage of children who screened positive, however, following evaluation by a child mental health professional, significantly more children of African American, Asian American, and Hispanic origin were determined to be in need of additional support. No racial or ethnic differences were found in the proportion that were successfully linked. The top six barriers to successful linkage as reported by parents included transportation, limited time availability, child discomfort with recommended plan, difficulty contacting provider, cost, and stigma. Significantly more Asian American, African American, and Hispanic parents than European American parents reported transportation and limited time as barriers. Significantly more European American parents reported child discomfort with recommended plan as a barrier. Overall, 94% of participating parents reported high program satisfaction.

Cost-effectiveness

Considerations of program costs and effectiveness enter into decisions as to whether to implement school-based mental health screening. Kuo et al. (2009) enumerated costs for DPSP screening and clinical evaluation in terms of labor and overhead and summarized program cost per enrolled student, per positive screen, and per referral. Cost-effectiveness was reported in terms of cost per student successfully linked to services. School demographics were used to generate a predictive formula for estimating the proportion of students likely to screen positive in a particular school, and this proportion can be used to estimate program cost. Program costs ranged from $8.88 to $13.64 per enrolled student, depending on the prevalence of positive screens in a school. Of students who were referred for services, 72% were linked to supportive services within six weeks. Cost-effectiveness was estimated to be $416.90 per successful linkage when 5% of students screened positive, and $106.09 when 20% screened positive. A formula for estimating the proportion of students who will screen positive was derived from information on a school's student population, including % male gender, % receiving reduced fee lunch, % English Language Learner, % Special Education, % single parent households, and % suspended in the past year proved accurate to within 5%.

Parental Permission

As mentioned previously, the Seattle Public School District's parental consent requirements were changed from passive to active between the 2002-3 and 2003-4 school years. The change in permission conditions provided a natural experiment to examine the differences in DPSP participation under active vs. passive consent ( Chartier, 2008). When children were required to have written parental permission (active consent), participation declined dramatically from 85% to 66%, compared to when parents were provided with written information and then had to actively decline in order for their child not to participate (passive consent). The decline in participation was disproportionately higher among subgroups of students who were at greater risk for depression. Thus, the requirement of active parental consent was associated with the unwanted effect of reinforcing existing disparities in access to mental health services.

Positive Predictive Value

A recurring concern in the arena of depression screening is the "false positive." When children who are not truly suffering from emotional distress screen positive, they and their parents can be subjected to undue apprehension and possibly stigmatization. Therefore, a screening program must choose a validated screening tool and must set a cut off level that optimizes the "yield" while reducing the number of false positives. During its eight years of implementation, DPSP has maintained a very steady positive predictive value of ∼60%. With a positive screen prevalence of 20 per 100, when the program screens 100 children, 8 will screen positive falsely and 12 will be "true positives." DPSP staff takes steps such to reduce students' anxiety around screening by ensuring confidential and up beat follow-up evaluations, by using non-stigmatizing language (distress, rather than depression), and by communicating in parent phone calls about the student's assets.

Linkage Success

A concern held by schools or communities is that universal screening will yield a need that is larger than the available resources. At the level of the individual child and family, this problem translates into the risk of identifying a problem, but not resolving it. There are many barriers to obtaining mental health services, including lack of mental health coverage by healthcare insurance plans, a large proportion of the population that is uninsured, and a lack of access to evidence-based treatments. As a result, communities are not ensured positive outcomes for persons experiencing emotional distress or even serious psychiatric disability, especially in the face of other pressing health, educational, or social concerns. Since 2005, DPSP has embedded a motivational interviewing component into the clinical evaluation, added a second follow-up phone call to parents who received recommendation for supports, and then tracked whether students were successfully linked to recommended supports through a call from a research assistant 5-weeks post-screening. Over the most recent four years of program implementation, research assistants make a 5-week post-screening phone call to parents to track the proportion of recommendations that result in successful linkage.

Pilot RCT

The 2008 iteration of DPSP included implementation of a small-scale randomized control trial ( McCormick, 2009). The trial investigated the impact of giving feedback to parents via telephone conversation with motivational interviewing (MI) versus giving feedback to parents via a mailed letter. Investigators hypothesized that parents in the telephone MI feedback condition would experience greater sense of urgency and empowerment and that as a result students of parents in this condition would:

1. be more likely to link to recommended services

2. experience lower levels of emotional distress by the 2nd semester of 6 th grade

3. experience a more positive middle school adjustment.

To assess emotional health outcomes (changes in depression and conduct problem scores), students who had screened positive in the fall received a second screening four months post-intervention, during the 2 nd semester of 6 th grade. School record data were used to ascertain GPA, attendance, and disciplinary actions. The previously described 5-week follow-up phone call was made to ascertain linkage status. After the second round of screening, staff surveyed parents and teachers to assess their satisfaction with the screening program.

Results showed that a higher proportion of students in the telephone MI feedback group (78%) were linked to recommended support services compared to the control group (36%) (1-tailed Fisher exact test, p=.06). In general, regardless of how parent feedback was delivered, students who screened positive and underwent the clinical evaluation reported significant declines in levels of depression symptoms, as well as conduct problems. Consistently better, but not statistically significant adjustment across three school indicators (GPA, attendance, disciplinary actions) was noted for students in the phone MI feedback condition. DPSP received high marks of satisfaction with students, parents, and teachers. Differences in parent reactions to the program were apparent in written comments. From a telephone MI feedback parent: "I got good follow-up on the phone call. [The CMHP] recommended talking to the teacher, which was great. [My daughter] formed a bond, and it's been really good for her to have support." From a parent who received feedback via mail: "Not sure what the program does. Just got the letter - not really sure what she got out of the meetings." Several parents in the control condition reported a desire for better communication during program implementation. In general, parents and teachers maintained high levels of agreement that mental illness adversely effects school performance and that students' mental health should be addressed in schools.

Of note is that each year that the DPSP has been implemented, a new evaluation question has been formulated and addressed. Implementation and evaluation costs have ranged from $10,000/year in one school to $30,000 in four schools. Originally funded as part of a larger National Institute of Health-sponsored epidemiological study, since 2005 DSPS has been supported by private foundations and individual donors. DPSP integrates program development, implementation, and evaluation at a low cost and provides a model for performing continuous quality improvement. Next steps are to design a larger randomized controlled trial.

Conclusions

In the past 20 years, school-based mental health programs have been created and modified, which has led to increased identification of at-risk students, connection of those students to appropriate services, and promotion of positive mental health at the individual and population levels ( Cassano & Fava, 2002). Successful implementation of school-based mental health programs warrants a careful consideration and examination of potential costs and benefits. This paper reports on the growing base of empirical evidence that addresses questions regarding the costs and effects of school-based depression screening.

Although we have presented some encouraging evaluation findings to support the implementation of school-based screening, the evidence base warrants considerable strengthening through application of rigorous research methods. Studies are needed that can make appropriate attributions of improvement in linkage to supportive services, decreases in emotional distress and increases in academic success. Randomized controlled trials of screening programs, while ideal for generating findings about program effectiveness, are challenging to implement. Three factors, in particular land scientists in a methodological quagmire. First, it is difficult to apply random assignment at the individual student level within a universal screening framework, and at the school level, it is difficult to ensure adequate comparability and power. Next, it is difficult to measure outcomes because it is difficult to know whether children's mental health status is improving without screening them. And finally, it is difficult to establish a strong comparison condition because it is unethical to refrain from following up with children who screen positive.

Besides the micro-level questions of whether program benefits can be studied, implementation of universal screening programs also warrants as a careful assessment of community readiness and interest among target groups within the community. While a recent study published in the American Journal of Preventive Medicine ranked depression screening among the top 25 preventive services offering the most health benefit for the health care dollar ( Johnson, 2006), implementation of universal screening of children remains controversial. Considerable public backlash was generated by recommendations from the New Freedom Commission to implement universal mental health screening in public schools. In 2004, the U.S. Congress proposed an amendment to an appropriations bill which would have prohibited funding for such programs ( Paul, 2004). Although the bill did not pass, some members of the media, the public, and Congress decried universal screening as coercive and potentially stigmatizing. Ultimately, critics accused screening programs of furthering the shadowy agenda of the pharmaceutical industry ( Conservative Caucus, 2004; Eakman, 2004). Fueling public apprehension about screening are reports of the recent upsurge in use of psychotropic medications such as Ritalin among school-aged children ( Dunn, 2002) and of drug companies and even the FDA failing to make public evidence of harmful side-effects of antidepressants for treating adolescents ( Shetty, R., 2004; Elias, 2004; Harris, 2004). Questions regarding the voluntary or mandatory nature of screening programs, the dissemination and use of screening results, and the interests and agendas of proponents and funders raise legitimate concerns that community stakeholders must address openly.

Meanwhile, depression and other mental health problems are taking a critical toll on school performance. An estimated 50% of failure to complete secondary school in U.S. population can be attributed to unaddressed mental health problems ( Vander Stoep et al., 2003). A legacy of school-based screening and treatment for health conditions, a surge in the development of promising school-based programs addressing mental health concerns, and a focus among policy-makers on preventing childhood depression ( Hoagwood, 2003) and "leaving no child behind" ( U.S. Department of Education, 2002) indicate that the public interest and technological expertise needed to address mental health concerns in the school setting are increasing. As Hoagwood has written, "Given the serious risks that children with mental health problems face in remaining intellectually and emotionally engaged in learning, the integration of mental health and educational perspectives are needed." With further evaluation and refinement, universal school-based depression screening may prove an effective means of detecting early precursors to mental health problems that can be readily addressed but if left unattended can escalate and seriously interfere with the cognitive, emotional and social development, reducing students' chances of academic success.

Contributor Information

Erin McCormick, University of Washington, Seattle.

Kelly Thompson, University of Washington, Seattle.

Ann Vander Stoep, University of Washington, Seattle.

Elizabeth McCauley, University of Washington, Seattle, Seattle Children's Hospital.

References

Conservative Caucus. Stop mandatory mental health testing. 2004 Retrieved 17, 2005, from http://www.conservativeusa.org/mentaltesting.htm.

McCormick E. Capstone Project Report, completed to fulfill requirements for Master of Public Health degree. University of Washington: Department of Health Services, Community-Oriented Public Health Practice Program; 2009. Vulnerable at transition: Assessing for distress in 6[th grade students. Google Scholar]

# data[].attributes.attachment_link.title
The Case for School-Based Depression Screening: Evidence From Established Programs

# data[].attributes.attachment_link.description
This paper reviews the evidence base supporting early detection of depression through school-based screening. An overview of the rationale for school-based depression screening is presented. Evaluation highlights from established screening programs based in secondary schools that have been reviewed in the mental health, public health, and educational literatures are described.

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Youth Descriptions of Mental Health Needs and Experiences with School-based Services: Identifying Ways to Meet the Needs of Underserved Adolesce

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Youth Descriptions of Mental Health Needs and Experiences with School-based Services: Identifying Ways to Meet the Needs of Underserved Adolesce

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J Health Care Poor Underserved. Author manuscript; available in PMC 2018 Apr 5.

Published in final edited form as:

Amelia R DeFosset, MPH, a Lauren N Gase, MPH, PhD, a Roya Ijadi-Maghsoodi, MD, b, c and Tony Kuo, MD, MSHS a, d, e

Abstract

While schools serve as a common entry point into mental health services for underserved youth, engagement of students in need of care remains a problem. Little is known about the ways schools can best address students' mental health needs, especially from the perspective of youth who struggle to attend school, a vulnerable group with a high burden of mental health problems. A qualitative descriptive approach was used to analyze data from in-depth interviews with a sample of 18 youth with a history of school truancy and mental health problems. Analyses explored how youth expressed mental health symptoms, and their trajectories through, and perceptions of, school-based mental health services. Results suggest that participants experienced multiple, overlapping symptoms; only a portion had their needs addressed. The quality of relationships with school staff and the perceived efficacy of treatment affected service trajectories. Promising school-based approaches to address students' mental health needs are discussed.

Keywords: Mental health, adolescents, schools, mental health services, qualitative

Mental health (MH) problems among youth, defined as experiences of emotional or psychological distress that affect daily functioning, are a serious public health issue in the United States. Annually as many as 20% of youth in the US are affected by MH problems that meet criteria for a mental disorder.1,2,3 Failure to address MH problems that emerge in adolescence, even symptoms that do not meet the criteria for a diagnosable disorder, can have severe consequences, including poor relationships, substance use, truancy, school failure, justice system involvement, and suicide.4,5,6 However most adolescents in need of care never receive it.7,8

Pathways to engaging youth in MH services begin with the identification of a problem, followed by a decision to seek or accept help, and end with selection and receipt of services.9 Multiple individual, interpersonal, and structural factors are known to influence service pathways.10,11 Underserved youth, in particular, racial/ethnic minority youth and youth from low-income households, face additional barriers that make them less likely to receive care.12

Schools are a common setting for recognizing and responding to youth MH needs, and underserved youth may be particularly dependent on them for care.13,14 Although schools use a variety of efforts to address the MH needs of students,15 evidence regarding their effectiveness for meeting the needs of underserved youth is mixed. Several studies document positive outcomes for students successfully engaged in care, such as reduced racial disparities in service use16,17 and improvements in acute symptoms (e.g., depression, suicidality).18 While promising, engaging the full population of youth in need remains a challenge. Minority youth tend to use fewer school-based services and to access them at a later age than their White peers.19 In addition, neither teacher reports of MH problems20 nor school-based referrals21 may ultimately lead to service use for minority youth.

Although school-based health services can remove certain barriers to treatment, breakdowns may still occur in pathways linking underserved youth to care. Decreased detection of MH problems among minority youth, potentially due to poor cross-cultural understanding or communication,22,20 may contribute to breakdowns in service pathways. Even when youth needs are identified, disparities persist in service linkages and completion, as school staff may be uncertain about how to address students' needs.23 Moreover, distrust of MH professionals, concerns about stigma, or difficulty identifying and accessing services (e.g., due to lack of insurance or transportation) may prevent minority or low-income families from seeking or finding help.24,21,14 Adding to this challenge are higher levels of school disengagement, truancy, and dropout among underserved youth.25 While researchers have largely not examined the provision of school MH services as it relates to youth with school attendance problems, it is reasonable to expect that educators may face additional challenges identifying and responding to the MH needs of students who are less present and engaged in school.

In spite of increased understanding of the challenges identifying and linking underserved youth to MH services, current research on factors affecting how they engage with school-based services is sparse, especially from the perspective of potential service-users. Much of what is known regarding how youth MH problems are identified and addressed is from the point of view of school staff,26 parents,20,10 or youth who were successfully engaged in care.26, 27 One of the only qualitative works examining youth perspectives on school-based MH services was conducted with participants who did not necessarily have MH needs or experience with MH services.27 While research clearly illustrates that not all youth in need of MH services receive them, limited qualitative information is available on factors that influence school processes for identifying and linking underserved youth to care.

To address this gap in the literature, this study reports findings from interviews conducted with a sample of racial/ethnic minority youth with a history of school truancy who reported experiencing MH problems. The first objective of this study was to examine how youth express their MH problems, especially within the context of their school attendance. The second objective was to describe youth experiences with and perceptions of school-based MH services. These youth-centered findings seek to inform school-based policies and programs to identify and address the MH needs of underserved youth.

Methods

The present study comprised a secondary analysis of 39 interviews conducted in the fall of 2013 to explore the experiences of youth with a history of school truancy in Los Angeles County.28 During the interviews, unmet MH needs emerged as a central theme when youth discussed their struggles to attend school. The present study analyzed data from 18 of the original 39 interviews with the subset of youth who reported experiencing MH problems, defined as emotional or psychological distress youth described as affecting their daily functioning, including but not limited to, their ability to attend school.

Setting and sample

This study used a community-partnered research approach in which three youth research assistants (recruited to optimize age, racial/ethnic, and experiential concordance with the intended sample) contributed to the development of the interview guide, recruited participants, conducted interviews, and assisted with data analysis. Interviews were conducted with 39 youth who: a) were a current or recent (within one year) middle or high school student in Los Angeles County, b) reported skipping class or ditching school at least once per month in the past year, c) had experience with at least one school-, community-, or law-enforcement-based truancy intervention, and d) spoke English or Spanish.28

Inclusion criteria for the present analysis were developed based on the Youth Self Report (YSR), a global measure of behavioral and emotional functioning of adolescents intended to assess distress along a spectrum, including at subclinical levels (e.g., by generating a continuous distress score). A short-form, 66-item version of the YSR has been previously validated and has demonstrated metric stability with diverse, non-clinical samples of adolescents in Los Angeles County.29 The short-form YSR includes an Internalizing Behavior Score (consisting of Somatic Complaint, Anxious/Depressed, and Self-harm Behavior sub-scales) and an Externalizing Behavior Score (consisting of Attention Problem, Delinquent Behavior, and Aggressive Behavior sub-scales). The short-form YSR was applied to the original study sample in order to identify the subset of youth with MH problems. Youth were identified as having a MH problem and included in the present analysis sample if they (1) reported or described at least three symptoms that were consistent with those from the short-form YSR and identified these symptoms as significantly impairing functioning or causing significant distress such that it shaped her/his life trajectory; or (2) reported experiencing, having been diagnosed with, or receiving treatment for any mental disorder recognized by the Diagnostic and Statistical Manual of Mental Disorders, 5 th edition (DSM-V).30 To identify eligible youth, two members of the study team engaged in two rounds of independent review of interview transcripts and discussion to resolve discrepancies.

Eighteen youth were included in the present sample. Ages ranged from 12-18, with a mean of 16.4 years. A majority of the sample was female (13 youth) and Latino (16 youth), with two participants identifying as African American (quantitative demographic information collected via a brief screening form administered at recruitment). Compared with the distribution of the original study sample, this subset contained slightly more youth who identified as Latino (89% vs. 80%) and female (72% vs. 51%). Youth in the present analysis were reflective of the original sample in terms of risk and experience; although youth were not asked to provide information on socioeconomic markers such as family income, parental education, or immigration status, youth commonly described exposure to conditions such as high rates of crime and violence, poverty, and family instability.

Procedure

In-depth interviews were conducted by one youth research assistant, assisted by one or two members of the study team.28 The 16-question open-ended interview guide asked participants to describe their story, from when they first started struggling to attend school and ending at the present day. Although youth discussed experiences related to MH problems throughout their interviews, questions that tended to elicit this content included: a) What happened that caused you to begin to cut or skip class? b) Why did you continue to cut or skip class? c) What happened when you were confronted about your attendance? d) How was your school/family/probation officer involved in your school attendance? and e) Can you tell me about any services you were offered or programs you may have participated in to improve your attendance? Interviews lasted approximately 30-40 minutes and were audio-recorded and transcribed verbatim.

All study protocol and instruments were reviewed and approved by the Los Angeles County Department of Public Health and the University of California, Los Angeles Institutional Review Boards prior to implementation. All study participants provided written assent. Participants were compensated with a $20 gift card for their participation.

Analysis

Qualitative data analysis for the present investigation occurred between July 2014 and February 2015. Two members of the original study team and one additional subject-matter expert in youth MH analyzed the 18 interview transcripts with a focus on understanding youth experiences of MH problems. In accordance with the qualitative descriptive paradigm,31,32 and mirroring the original study,28 data were analyzed using a bottom-up inductive technique. The two members of the original study team used close and holistic coding (e.g., development of holistic case summaries) to identify key influences, events, and experiences. The two met after independent review of sets of three to four transcripts to discuss, and then finalize, a coding and thematic scheme, and twice with the external subject-matter expert to understand how youth descriptions compared with clinical definitions and contexts. Data management and analysis was conducted using ATLAS.ti version 7.33

Results

Youth descriptions and expressions of MH problems

Youth described experiencing overlapping symptoms of MH problems; the most commonly reported included anxiety or depression, delinquent behavior, and physical or verbal aggression. The majority of youth reported both internalizing symptoms (e.g., worry, withdrawal) and externalizing symptoms (e.g., fighting, lying). For instance, close to two-thirds of the youth with histories of physical or verbal aggression (seven out of 11) and delinquent behavior (eight out of 12) also described symptoms of anxiety or depression. Less than half of youth explicitly discussed having a MH disorder using clinical terms, such as depression or anxiety; when they did, it was not always clear if the language used reflected having received a diagnosis or that the participant was looking for a way to name and discuss her/his experience. Youth descriptions of their symptoms, as well as how these symptoms related to school attendance and other problematic behavior, are presented in Table 1 .

Table 1

Category

Youth Descriptions of Symptoms

Associated Behavior²

Illustrative Quote

Number of Participants³

Anxiety/Depression

'Having problems'
'Just not able to deal with it'
'Going through a depression'
'Stressed'
'Everything is too much'
'Just didn't care at that moment'

Missing school

Due to feeling overwhelmed by emotions

...it's too much for me because, one of my illnesses is anxiety. I have panic attacks, so when I'm put into too much pressure, I can't handle it, and I can't be put in a classroom where I know the teacher dislikes me and I can't handle being in that type of environment. So to me it's too much, so I like can't be in class (#27).
...you don't want to get out the bed. You don't want to get out of the house so, I would just stay home and not go out. That was me for a week straight. And then I would go [to school], and be like I'm not really doing anything here so I would just stay home for another week. And that's how it was once in a while (#11).

14

Delinquent Behavior

'Hanging with the wrong crowd'
'Being in a clique/crew'
'Being a follower'
'Chilling'
'Partying'

Gang involvement
Alcohol and substance use
Missing school

to use drugs or hang out with delinquent peers

When I got to 8th grade, I would skip class to skate and go have fun. I would hop on a metro and, like, just by myself...but, when I was in school, I would cut class just to go smoke or something, and then come back and be all loaded and retarded. Yeah, that was when I was in 8th grade. When I was in 8th grade, I was hanging out with the bad people...really bad people. It wasn't with skaters no more...it was just people in gangs, you know, crews (#32).

12

Physical/Verbal Aggression

'Bad attitude'
'Getting in fights for no reason'
'Holding grudges, not letting things go'
'People irritate me'
'I wake up mad'
'Bipolar'
'Anger issues'

Physical fights
Yelling, arguing
Arrest and Probation
Missing school

To avoid specific conflicts

To avoid general (potential) conflicts

I would get mad for the weirdest things ever, like I would see a kid on the side, making a sound with his mouth and I'd be like 'hey can you shut the fuck up?' and you know the kid if he don't shut up then I'm gonna' fight, it's crazy man, I had issues. I would fight literally like every day, you could ask anybody, like I'm bipolar and anger seems to be a way...like, the one that got the biggest fraction of all of them (#1).
Sometimes in fifth period, it's really stressful, so I always end up going to my sixth period bad. So instead of snapping, ever since [a previous physical fight], I always stay outside for a while and sometimes it takes me the whole day to calm down so I don't go to class for my last period (#30).

11

Somatic Complaints

'Having a sickness'
'Vomiting'
'Trouble sleeping'

Missing school due to perceived or actual physical symptoms

...right now I'm drinking sleeping pills because I can't sleep. But the doctor told me the sleeping pills should work, but I've been drinking them...he told I'm just supposed to drink one, but if they don't work I'm supposed to be drinking two, but I drink two and I still be awake, you know, the whole night. And I be thinking, like, it's because of the stress that I be going through (#37).

2

Self-harm

'Hurting myself'
'Wanted to die'

Harming self
Verbal expressions of suicidal ideation

When we broke up it just brought me down, like, to a point where I didn't want to live, like, I wanted to die and, you know, I didn't even want to go to school. In 11th grade that's where, um 11th, 12th, I just started falling apart (#13).
When I was in 8th grade, I had so many problems, because I was getting punked on and I would skip class and I would, um, harm myself (#30).

2

Youth pathways through MH services

As depicted in Figure 1 , the majority of youth did not follow an ideal pathway linking them to needed MH services. Seventeen of the 18 participants reported contact with an adult related to their symptoms, representing an opportunity for their needs to be identified. Eleven contacts occurred in schools, whereas six were facilitated by other systems. Thirteen of these youth were offered services, and nine ultimately received services. Youth experiences are described below, followed by a discussion of crosscutting factors that influenced how they perceived and engaged with MH services and supports.

Opportunities for needs to be identified

All but one youth described having contact with an adult related to her/his MH needs. The majority of these contacts occurred in schools, almost exclusively initiated by school staff (as opposed to youth or their families). These encounters included both formal (e.g., meetings with their family and school administrators) and informal (e.g., being pulled aside by teachers and asked about poor attendance) responses to problematic behavior. Formal intervention usually occurred when youth got in trouble, (e.g., for fighting) or when their attendance problems had reached a critical stage (e.g., they had too few credits to graduate); youth described these encounters as primarily focused on discipline, where, if services were offered, they were offered in tandem with sanctions. Six youth had their needs identified for the first time outside of school, usually after something serious happened: three youth after being arrested and placed on probation, and two after a hospitalization. For example, one 17-year-old girl (#37) with a history of fighting, expulsion, and gang involvement was hospitalized for a drug overdose following the shooting death of her boyfriend. As her case illustrates, the paths of these youth were characterized by multiple warning signs, but no prior reported intervention by schools or families.

Services offered and received

Of the 17 youth who had contact with an adult related to their MH needs, 13 youth reported being offered services, while four did not. Missed opportunities for service linkage were related to the reactions of both the youth and adults; youth were not always willing to engage when adults tried to reach out (see later discussion of influences on youth service pathways) and adults did not always successfully link youth to services, even when they were receptive. In one notable example, a 17-year-old girl with a history of aggression, repeated expulsions, and arrest describes her experience reaching out to a school counselor:

...I remember one time I went to my counselor and I'll be like, "Oh can I talk to you? This is what, I've been having problems." He's like, "No, no, no." He's like, "I don't deal with problems." He's like, "I don't deal with problems, I deal with classes." He's like, "I give you your classes but I don't deal with problems." I was like, "OK, and that's it." That was the last...that was the first and last time I ever talked to a counselor (#3).

Another 16-year-old girl described a similar experience, in which a service provider who was recommended by her probation officer, failed to follow up to offer anger management classes, although she emphasized the seriousness of her problem during the interview, saying " I have anger issues, very very very very anger issues [#28]." When service pathways were hard to navigate or disjointed it led to feelings of rejection or the perception that no one cared enough to help.

Half of the youth in the sample (nine) received at least one formal MH service or support. Three enrolled in anger management classes, five received counseling, and two were prescribed medication. As described further below, youth levels of satisfaction with the services provided were mixed.

Main influences on youth MH service pathways

Youth described a variety of individual, interpersonal, and contextual factors that influenced how they perceived and engaged with MH supports and services. Two overarching themes were identified: 1) the quality of relationships and the setting in which services were offered and, 2) the extent to which youth believed their situation would be improved by professional care (i.e., perceived efficacy of seeking help).

Quality of relationships and setting

While most (11 youth) acknowledged the need to talk about their problems to move past them, not all were willing to do so if they did not have a positive relationship with the adult reaching out. Several youth spoke about the importance of a shared background or extended relationship with an adult with whom they could confide. This was the case for one 16-year-old girl who discussed her relationship with a staff member at the community center who was influential in changing her behavior, where others were not:

...she met me since I was little, so with her, I tell her my problems, she helps me out. She has more pressure on us about going to school than the probation officers (#28).

However, even when there wasn't necessarily a long-standing relationship, youth seemed willing to open up to adults they felt genuinely cared for them and believed in their ability to succeed academically. For instance, one 17-year-old girl described the importance of a relationship with a teacher at her continuation school:

...she always talk to me, like she been there when my boyfriend passed away, you know, she was right there, like, "You're young, you could still keep on going to school," like, "It's going to get in your way sometimes," but she would always talk to me like, "Oh, why you missing school?" like about, "Why you not coming to school?" Like, she don't talk to me in a mean way, like, "We're going to kick you out" (#37).

In contrast, the effect of contentious relationships with school staff is illustrated by one 17-year-old boy who was frequently absent following a death in his family, but hid the reason from his teachers because it was " personal," instead saying he was " just sick" (#8). Overall, his narrative regarding teachers is dominated by phrases such as, " He thought I was dumb," " The teacher didn't like me much," and " They single you out" and a general feeling of being confronted, judged, and dismissed. Similarly, at least two youth described being suspicious of the motives of services offered through school or probation. For example, one 18-year-old girl reflected on school-based counseling services as being just focused on " how to progress in school " and ultimately not helpful (#11). Finally, the desire for greater understanding was echoed by two youth who reported having been diagnosed with a mental illness. Despite taking steps to document their health problems with the school district, both reported feeling judged and penalized by teachers, which led them to further disconnect. One 14-year-old girl described her interactions with her teachers this way:

...because I have everything filled out the teachers are not allowed to be saying anything. But they still would. Like all the medical papers and everything were signed and shown, but they just didn't believe it and they thought because I was missing so much school that it wasn't true. So I was just like, "Ok, if you aren't believing me and you're just going to talk down, it's like what's the point of me being in your class?" (#27).

Perceived efficacy of seeking help

Youth attitudes and beliefs regarding the efficacy of MH services affected how they responded throughout their service pathways. When youth reflected on their MH needs, at least seven participants felt there was "nothing anyone could do" to fix it and emphasized the role of personal will-power. For instance, one 18-year-old girl reported rejecting school-based counseling services, saying, " It just really doesn't work cause like there's not much you can do about [depression] [#11]" and returning to school after she " stopped making excuses." Similarly, several youth who reported experiencing anger management problems described controlling their behavior after they decided to change their " attitude" or " relax."

Although some youth expressed fatalistic attitudes regarding formal MH services, others appreciated learning techniques and approaches for coping with their emotions. These experiences were described by one 18-year-old boy who was connected to anger management through his school counselor:

...it helped, ...we'd play games and talk about all of our problems and ways to improve it and to fix it and ways to manage your feelings and to control them, and I could not control my anger [before] but now ... it's not a big problem, it's still a problem yeah, now and then when it has to be, but ... I've learned ways to get through the obstacle without being physical (#1).

Of the nine youth who received services or supports, four reflected on them as being helpful and contributing to their healing; two received anger management and two received counseling or other support services. These youth described long-term relationships with service providers, learning skills or techniques for coping with negative emotions, being able to share their experiences with adults who they felt understood their backgrounds and experiences, and having someone who cared enough to listen, as valuable to their recovery.

Discussion

This qualitative study sought to explore how low-income, racial/ethnic minority youth with a history of school truancy expressed MH symptoms and experienced school-based MH services. While youth described multiple MH needs related to their struggles to attend school, only half received services to address them. There were several points where breakdowns occurred in pathways linking youth to care: MH needs were not identified, services were not offered, and youth did not participate. Poor relationships and a prevailing belief that there was nothing anyone could do to help contributed to disjointed service pathways.

Many youth in the present study described overlapping symptoms of MH problems. Findings are consistent with evidence of comorbidity between internalizing and externalizing disorders and suggest that easily identifiable problem behaviors, such as frequent fighting, may be symptomatic of a range of underlying MH needs.34,35 Results also align with emerging evidence on the reciprocal relationship between MH and school engagement.36,25 Findings illustrate how MH symptoms (e.g., acting aggressively in class, seeming apathetic about school) may contribute to adversarial relationships with school staff, causing additional distress, disengagement, and truancy. Unfortunately, youth in the present study were often provided MH services secondary to disciplinary action; being identified as truant largely did not trigger a formal or comprehensive MH evaluation and many youth were significantly off-track academically or had been expelled by the time their needs were identified. These experiences support previous studies on the consequences of untreated MH problems, especially regarding academic failure and impaired relationships37,38 and point to the importance of identifying the full extent of MH needs early and advancing more comprehensive strategies to improve youth wellbeing.

Results of the present study suggest that poor relationships with adults and negative attitudes held by youth towards MH services were major barriers to addressing MH needs in schools. In particular, many youth were reluctant to confide in teachers they felt did not support them, or they disengaged when they felt their needs were not understood. Other qualitative work on help-seeking behaviors in schools highlights the importance of sustained and supportive relationships with adults.27 While some youth in the present study described these types of positive relationships, overall, their school experiences were largely negative and unstable (e.g., expulsions or forced transfers, gaps in enrollment), decreasing opportunities to foster healthy relationships and to identify MH needs. In addition, youth skepticism regarding MH care affected how they disclosed their problems or engaged with service pathways. Although related in part to the context in which services were offered, attitudes of many youth reflected a fatalism regarding the efficacy of professional care and a preference for self-reliance, cognitive attributes that are well documented among low-income and minority youth.9 Concerns about stigma were also evident in youth accounts-for example, youth tended to label MH problems as physical in nature or describe symptoms using vague terms. Stigma may be of particular concern for minority youth,12 adding to the barriers that prevent help-seeking.

Implications for practice

Results point to the need for enhanced school-based approaches to address MH problems, especially among underserved youth. Comprehensive school health approaches, such as those recommended by the Whole School, Whole Community, Whole Child (WSCC) model, may offer a pragmatic framework. The WSCC model emphasizes the importance of efforts to promote health among the school community holistically, in addition to providing integrated health services for those in need of care.39

One cornerstone of this comprehensive approach, supported by the present analysis, involves identifying youth in need. Although teachers are central in recognizing and responding to youth problems, they may lack the training or professional support needed to engage students and to assess their MH needs.23 In the short term, in districts where dedicated mental health staff is scarce, teachers could be better trained and supported to address their students' MH needs. However, broader, more sustainable efforts are needed in the long-term. School districts and policymakers should prioritize adequate staffing of MH professionals at school sites, beginning with districts that have high concentrations of youth at risk for MH problems (e.g., those with high rates of truancy and exposure to violence, trauma, and poverty).

Implementing universal, comprehensive MH screenings may provide a structured mechanism to improve detection of students in need and ease the burden on school staff. However, early detection is of no value if the infrastructure is not in place to appropriately refer and/or treat all youth who are identified.40 Even so, in high-need, under-resourced schools, providing targeted screening and comprehensive MH evaluations may be a potentially cost-beneficial intervention for youth with school attendance problems. Despite the link between truancy and unmet MH needs, many schools do not routinely incorporate referrals to MH services in truancy reduction interventions, perhaps contributing to the limited impact of these efforts.41-43

Finally, results point to the need to improve MH literacy, reduce stigma, and build sustained and supportive relationships with adults as part of a comprehensive, integrated school wellness strategy. Youth ambivalence towards seeking and receiving MH services points to the importance of creating school communities in which help-seeking behaviors are normalized and facilitated by relationships with trusted adults. Culturally relevant school-wide interventions to reduce stigma and promote a healthy school climate represent a promising approach.44, 45

Limitations

Although this study provides important insights into youth perspectives, it has a number of limitations. First, like most qualitative research, results are not intended to be generalizable. All youth in the present study had a history of truancy; experiences of this group may not be reflective of youth who consistently attend school or of low-income, minority youth generally. Second, the present study was a secondary analysis of data collected to address a different set of research questions. In the original study, participants were not directly asked about their MH needs or experiences; themes related to MH emerged from youth descriptions of their school attendance history and probes were used to elicit details. Inclusion criteria, developed based on the short-form YSR and in consultation with the subject-matter expert, were applied post hoc to the original sample to categorize youth as "experiencing MH problems" or "not," but do not provide information on their relative level of distress. It is possible that youth with lower levels of symptoms were omitted from the sample. Third, to maximize the comfort of participants and limit concerns over confidentiality, participants were asked to provide only limited quantitative demographic information. Inferences regarding the makeup of the sample in terms of socioeconomic characteristics, such as family income, are based on descriptions present in youth narratives. Finally, it is unclear to what extent youth reports of their service pathways are comprehensive or accurate.

Conclusions

Youth who struggle to attend school may have complex MH needs and may face significant barriers to MH care. Although schools are uniquely positioned to address these needs, modifications to current systems and practices are needed to adequately identify and engage youth in need of care. In particular, poor relationships with school-based adults and low perceived efficacy of professional treatment may prevent youth from disclosing symptoms or engaging with available services. Increased screening, including evaluating MH problems among youth with school attendance problems, coupled with efforts to increase readiness of school staff to respond to MH needs, build relationships, and reduce stigma may support early detection and treatment of underserved youth with MH problems.

Acknowledgments

The authors thank Juan Pena, Mario Rodriguez, and Nafeesa Toney from the Youth Justice Coalition for serving as youth research assistants. The authors also thank Raymond Perry from the Los Angeles County Department of Health Services, for his contributions and support.

Funding sources: The research described was supported in part by the NIH/National Center for Advancing Translational Science (NCATS) UCLA CTSI grant numbers UL1TR000124 and TL1TR000121. Dr. Ijadi-Maghsoodi was supported by the VA Office of Academic Affiliations through the VA Advanced Fellowship in Women's Health and by the National Institute on Drug Abuse of the Nations Institutes of Health under K12DA000357.

Footnotes

Conflict of interest statement: The authors report no conflicts of interest or financial disclosures.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views or the official position of the Los Angeles County Department of Public Health, the University of California, Los Angeles, the US Department of Veteran Affairs or the United States Government, the National Institutes of Health, or the funding agencies.

References

2. National Research Council (US), Institute of Medicine (US) Committee on the Prevention of Mental Disorders. Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions. In: O'Connell ME, Boat T, Warner KE, editors. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington (DC): National Academies Press (US) National Academy of Sciences; 2009. [[ PubMed] Google Scholar]

36. Dembo R, Wareham J, Schmeidler J, et al. Differential effects of mental health problems among truant youths. J Behav Health Ser R. 2014:1-26. [ Google Scholar]

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Youth Descriptions of Mental Health Needs and Experiences with School-based Services: Identifying Ways to Meet the Needs of Underserved Adolescents

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While schools serve as a common entry point into mental health services for underserved youth, engagement of students in need of care remains a problem. Little is known about the ways schools can best address students' mental health needs, especially ...

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You are a trusted resource for your child when they have questions about life and the changes they experience as they get older. Here you'll find information on mental health conditions, risk factors and warning signs of mental illness, and practical ways you can help support your child's mental health and well-being. It all begins with a conversation.

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You are a trusted resource for your child when they have questions about life and the changes they experience as they get older. Here you'll find information on mental health conditions, risk factors and warning signs of mental illness, and practical ways you can help support your child's mental health and well-being.

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How Schools Can Support Students Mental Health

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Looking after students’ mental health and wellbeing should be one of the top priorities of any school. Learn what staff can do to better support kids.

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To find a course or Instructor near you, enter your location below. You may then narrow your search by using the check boxes to the left of your screen.

Why Mental Health Matters in Schools

One in five children aged 13-18 (22 percent) will experience a severe mental health disorder at some point during their life.

More than 37 percent of students with a mental health condition age 14 and older drop out of school-the highest dropout rate of any disability group.

How Youth Mental Health First Aid Can Help in Schools

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Mental Health First Aid in Schools Youth Mental Health First Aid is an 8-hour public education program that introduces adults to the unique risk factors and warning signs of mental health problems in adolescents, builds understanding of the importance of

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Our Turn to Talk is a digital-first documentary about the mission to end stigma around mental health challenges, starting with the next generation. In this character-driven film, we go behind the scenes of a podcast production bringing together teens from all walks of life to use storytelling to bravely share their mental health journey without fear, shame or stigma.​

​Join these youths as they step into their voice and learn to create space to share the impact on their mental health of social media, sexual identity, gender identity, racism, and the pandemic. Premieres Fall 2022.
Production Credits
Our Turn to Talk is co-produced by WETA and Principle Pictures and features storytellers from This Is My Brave, an organization that uses performing arts to fight stigma around mental health challenges and addiction.

Kelly Deckert, Executive Producer
Justin Rhodes, Executive Producer
Rose-Marie van Otterloo, Executive Producer
John Wilson, Executive Producer
Beth Murphy, Director, Co-Producer
Patrice Howard, Director, Co-Producer

Inspired by This is My Brave, founded by Jennifer Marshall.

Special thanks to Wendy Shattuck, Fred and Michelle Grubb, Kris Trustey, Maribeth Brostowski, Suzanne Garverich, Mary Susan Hulefeld, Sumner Saitz, Tara Dean, Lauren Chiarello, Crystal Kjelsberg, Alison Lehane, Jane Tyler, Julia Carpenter- Conlin, Jennifer Famiglietti, Kathryn Burns, Terry Logan, Margaret Catagnus, Kristin Pedemonti, and Margaret Martin.
Original Production Funding for OUR TURN TO TALK was provided by
Ruderman Family Foundation, Alkermes, Sage Therapeutics, Wendy Shattuck, Fred and Michelle Grubb, Kris Trustey, Maribeth Brostowski , Suzanne Garverich, Mary Susan Hulefeld, Sumner Saitz, Tara Dean, Lauren Chiarello, Crystal Kjelsberg, Alison Lehane, Jane Tyler, Julia Carpenter- Conlin, Jennifer Famiglietti , Kathryn Burns, Terry Logan, Margaret Catagnus, Kristin Pedemonti, Margaret Martin

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Our Turn to Talk: Watch the Film - Well Beings

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Dive deep into the personal lives of talented teens who are preparing for a high school stage production that welcomes teens from all walks of life to stand up on stage and bravely share their mental health stories without fear, shame or stigma.

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Below is a compilation of resources that are referenced in the Classroom WISE online course. All resources were developed by the MHTTC Network and the National Center for School Mental Health for Classroom WISE, unless otherwise noted. A complete list of Classroom WISE resources is available here.

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Below is a compilation of resources that are referenced in the Classroom WISE online course. All resources were developed by the MHTTC Network and the National Center for School Mental Health for Classroom WISE, unless otherwise noted. A complete list of Classroom WISE resources is available here.

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Example of school resource for families and students

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Example of school resource for families and students

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Social Emotional Wellness for Families and Students

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Text HOPE4SC to 741741 to connect with a crisis counselor.

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WELL BEINGS: Mental Health in the Classroom

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Center on PBIS | Resource: Parent Letter: What is PBIS

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Word Doc: A sample letter to parents announcing that the school is engaging in PBIS, what PBIS is, and what to expect.

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(2020, March 31) | Useful for sharing with families to support positive behavior.

This 8-page brief speaks directly to parents about how to use positive behavioral interventions and supports (PBIS) at home, an approach used in over 25,000 schools as a highly effective way to build children's social-emotional-behavioral skills and reduce challenging behaviors. The publication is a collaboration between the Center on Positive Behavioral Interventions and Supports (PBIS) and the Center for Parent Information and Resources (CPIR), and is a direct response to current stay-in-place policies and school closures resulting from the COVID-19 pandemic.

The recommendations in the brief start with setting routines. Examples are given as to how to adapt school use of PBIS to home use for both elementary and secondary school routines. Another recommendation is to set home expectations of behavior. Again, examples are given of how expectations at school can be adapted to expectations at home. A third recommendation focuses on emphasizing positive feedback over correcting behavior (rule of thumb: aim for a ratio of 5 positive to 1 corrective). This recommendation includes strategies such as reminding children about expectations before an activity and rewarding positive behaviors. Additional recommendations are given about communicating with the school, being creative, and modeling good behavior and well-being.

For your convenience, you can access the brief right here at CPIR:
https://www.parentcenterhub.org/wp-content/uploads/repo_items/supporting-families-pbis-at-home-final.pdf

The brief is also available at the the Center on PBIS.

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Looking for more information and resources on COVID-19, official guidance from the federal government and others, schooling at home, technology tools, or coping tips? Visit our page on Coronavirus Resources. We update the list constantly.

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(2020, March 31) | Useful for sharing with families to support positive behavior. This 8-page brief speaks directly to parents about how to use positive behavioral interventions and supports (PBIS) at home, an approach used in over 25,000 schools as a highly effective way to build children's social-emotional-behavioral skills and reduce challenging behaviors.

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PPTs on Specific Disorders and Classroom Guides

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PPTs on Specific Disorders and Classroom Guides

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Be sure to look at the menu on the left of the page!

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For Professionals | School Based Behavioral Health (SBBH) | University of Pittsburgh

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Professionals working in school-based behavioral health will find many resources on this page. Students and the faculty members in the University of Pittsburgh’s School-based Behavioral Health Specialization have developed professional development resources including slide presentations and accompan…

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Films on mental health for families and students

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Films on mental health for families and students

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The Creative Coping Toolkit (CCT) is a highly regarded film program that supports social-emotional learning, endorsed by educators, and experts worldwide.