September 2023
NEW YORK ASSOCIATION OF SCHOOL PSYCHOLOGISTS
A Roadmap for School-Based Mental Health Services
On the road to better youth mental Health
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Executive Summary
On the Road to Better Youth Mental Health: A Roadmap for School-Based Mental Health Services
New York State's FY 2024 Executive Budget includes a comprehensive $1 billion multi-year plan to transform the continuum of mental health care and drastically reduce the number of individuals with unmet mental health needs throughout the state. Governor Hochul first outlined this multi-year plan during her 2023 State of the State Address. Her plan will dramatically expand access to mental health care, reduce wait times, and ensure appropriate levels of care to correct our mental health care system, which has suffered from chronic underinvestment. The New York Association of School Psychologists (NYASP) is the state-wide professional association representing the thousands of school psychologists working in New York’s public and private schools, Early Intervention and preschool programs, colleges and universities, and New York State agencies. As front-line mental health professionals, school psychologists, along with our school social worker, school counselor, and school nurse colleagues, are confronted with the realities of an increasing need for mental health services and limited availability of access to resources for children and youth. NYASP is encouraged that the Governor has included a focus on school-based mental health services for children and youth. Schools have become the de facto mental health system for children in our country. Good mental health is critical to children’s success in school and life. Providing a continuum of school mental and behavioral health services is critical to effectively addressing the breadth of students’ needs. Comprehensive mental health services are most effective when provided through a Multi-Tiered System of Supports (MTSS). MTSS encompasses the continuum of need, enabling schools to promote mental wellness for all students, identify and address problems before they escalate or become chronic, and provide increasingly intensive, data-driven services for individual students as needed. MTSS is an umbrella term for an approach designed to respond to the needs of all students within a system that integrates, but is not limited to, tiered behavioral supports, and is part of the structure of a comprehensive school-based mental health system. MTSS is a school-wide, data-driven, prevention-based framework for improving learning and adjustment outcomes for all students through a layered continuum of evidence-based practices and systems. Universally offered Tier 1 services (i.e., services offered to all students within a school system) typically include widespread screening, social-emotional based learning curricula, and prevention-based activities that foster healthy functioning in a positive school climate. Tier 2 services allow for early intervention and targeted support (i.e., for students exhibiting risk factors often associated with potential issues but for whom the issues have not fully manifested), and may include more direct student screening and interventions to reduce the likelihood of issues developing or to resolve present concerns. Tier 3 services are generally for students identified as experiencing mental health difficulties, and may include individual or family/caregiver treatment or other individualized interventions to address the identified mental health challenge. Potential barriers for the implementation of comprehensive mental health services can be overcome through current grant funding at the state level (e.g., RECOVS Grants) and at the federal level (e.g., Bipartisan Safer Communities Act). Funding from these sources can ensure proper school-employed mental health professionals ratios, as recommended at the federal level (e.g., school psychologists, 500:1). It is critical for schools to employ enough mental health staff to provide comprehensive services. Selection of curriculum and programs at the different tiers should be a collaborative process, with representation from different stakeholders (including students) being part of the decision-making process. Professional development and other staff training needs to be offered to ensure appropriate knowledge and skills to implement school-wide programs. Mental health services need to be part of the core mission and priorities of schools and be given the proper time to be infused within the classrooms and structure of the school day. Finally, access to community mental health services is a critical part of a comprehensive plan. Partnering with community agencies, hospitals, and other resources can enhance and support school-based services. However, addressing critical shortages of community mental health providers for children and youth needs to be addressed. Legislative solutions, such as licensing school psychologists to increase the community mental health workforce, need to be enacted. On the Road to Better Youth Mental Health: A Roadmap for School-Based Mental Health Services offers guidance on using a MTSS framework to structure comprehensive and effective mental health services in schools.
Setting the stage
New York State's FY 2024 Executive Budget includes a comprehensive $1 billion multi-year plan to transform the continuum of mental health care and drastically reduce the number of individuals with unmet mental health needs throughout the state. Governor Hochul first outlined this multi-year plan during her 2023 State of the State Address. Her plan will dramatically expand access to mental health care, reduce wait times, and ensure appropriate levels of care to correct our mental health care system, which has suffered from chronic underinvestment. The New York Association of School Psychologists (NYASP) is the state-wide professional association representing the thousands of school psychologists working in New York’s public and private schools, Early Intervention and preschool programs, colleges and universities, and New York State agencies (e.g., OPWDD, OMH). The mission of the Association is that NYASP empowers school psychologists to enhance the learning, as well as the mental/behavioral wellness of youth and families across all environments. School psychologists are highly trained in both psychology and education. Their training emphasizes preparation in mental health and educational interventions to address psychopathology and other barriers to learning, child development, learning, behavior, motivation, curriculum and instruction, assessment, consultation, collaboration, school law, and systems. NYASP has been a strong advocate for increasing access to mental health services for children and families. As front-line mental health professionals, school psychologists, along with our school social worker, school counselor, and school nurse colleagues, are confronted with the realities of an increasing need for mental health services and limited availability of access to resources for children and youth. In the past year, even as the nation has returned to “normal” life, the latest research shows that many students are still living in a state of mental health crisis. This data isn’t at all surprising to educators and parents. Based upon a report from the NYS Office of Mental Health, New York State, like the rest of the nation, is experiencing a youth mental health crisis. According to the CDC Youth Risk Behavior Survey, from 2011 to 2021, the rates of youth who persistently felt sad or hopeless increased from 21 percent to 29 percent for teen boys, and from 36 percent to 57 percent for teen girls. Those who reported that they seriously considered attempting suicide increased from 16 percent to 22 percent over the same period. According to an April 2022 Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR), when compared to students who felt close to persons at school, youth who did not feel close to persons at school reported higher rates of the following: poor mental health during the last 30 days and during the pandemic, persistent feelings of sadness or hopelessness, and having seriously considered attempting or having attempted suicide. Further exacerbating the mental health crisis among youth is the public health crisis of racism. According to the CDC (n.d.), “A growing body of research shows that centuries of racism… has had a profound and negative impact on communities of color. …social determinants of health – are key drivers of health inequities within communities of color, placing those within these populations at greater risk for poor health outcomes.” Racism can negatively impact mental health and contribute to unequal access to resources and services, including mental health care. First-hand experiences of racial discrimination, as well as witnessing or hearing about discrimination from others or in the media, can cause or intensify stress and racial trauma. The impact of systemic racism on the mental health of Black, Indigenous, and People of Color (BIPOC)/youth of color was evident in that racism causes trauma and trauma is directly related to mental illnesses. On a national scale, youth presentation for suicidal and self-harming behaviors in emergency settings has also increased, with large increases in teenage girls and LGBTQ-identifying youth. According to the Trevor Project’s 2022 National Survey on LGBTQ Youth Mental Health, young black people have experienced an increase in suicide attempts, with suicide rates among young black people increasing 37 percent between 2018 and 2021. Black transgender and nonbinary young people also reported higher rates of all indicators of poor mental health compared to their Black cisgender LGBTQ peers. Relatedly, there is growing concern about the negative impacts of social media on youth mental health. Governor Hochul’s call for an examination of youth mental health in New York State, including the impact of social media, is aligned with US Surgeon General Murthy’s advisory on Social Media and Youth Mental Health detailing these impacts.
It's time we put the mental well-being of our youth at the forefront and listen to what they're going through to gain a deeper understanding of this issue and meaningfully address the problems young New Yorkers face. - Governor Kathy Hochul
" The bottom line on student learning today is this...You can't teach if you're not addressing mental health" - Rene Myers, Teacher
NYASP is encouraged that the Governor has included a focus on school-based mental health services for children and youth. One in five children is adversely affected by a mental health condition. Estimates of the children impacted by mental health issues have grown over the past few years. However, less than half of these children will receive treatment and of those who do, most receive fewer than four sessions of care in community mental health settings. For youths living in poverty, without insurance, or from racial-ethnic minority groups, access to mental health treatment is even more limited. Many of these youths do not receive mental health care; rather, their mental health conditions are often managed in the juvenile justice system. When children are able to access mental health care, almost two-thirds receive services within the school setting. Schools have become the de facto mental health system for children in our country. When mental health services are not accessible to children in their communities, the onus falls on school systems, which don’t have the option to turn students away. However, schools provide an ideal context for prevention, intervention, positive development, and regular communication between school and families. School-employed mental health professionals (e.g., school psychologists, school counselors, school social workers, and school nurses) have built strong relationships with students, parents, and other staff, which contributes positively to accessibility of services. Research shows that students are more likely to seek counseling when services are available in schools. In some cases, such as rural areas, schools provide the only mental health services in the community. Comprehensive, culturally responsive school mental health services can help address inequities in access and help reduce the stigma associated with receiving mental health services by making it part of the fabric of the school system. Good mental health is critical to children’s success in school and life. Research demonstrates that students who receive social–emotional and mental and behavioral health support experience better academic achievement. School climate, classroom behavior, engagement in learning, and students’ sense of connectedness and well-being improve as well. Mental health is not simply the absence of mental illness but also encompasses wellness promotion; social, emotional, and behavioral health; and the ability to cope with life’s challenges. Left unmet, mental health problems are linked to costly negative outcomes such as academic and behavior problems, dropping out, and delinquency. Mental and behavioral health problems not only affect students’ short-term classroom engagement, but also interfere with long-term development of positive relationships and work-related skills. While most reports have focused on the intensive services provided by schools to students significantly impacted by mental health issues, it is vital to also focus on prevention strategies, the promotion of mental wellness, and early intervention for youth who are beginning to display signs of poor adjustment. Providing a continuum of school mental and behavioral health services is critical to effectively addressing the breadth of students’ needs. Comprehensive mental health services are most effective when provided through a Multi-Tiered System of Supports (MTSS). MTSS encompasses the continuum of need, enabling schools to promote mental wellness for all students, identify and address problems before they escalate or become chronic, and provide increasingly intensive, data-driven services for individual students as needed. Access to adequate staffing of school-employed mental health professionals, like school psychologists, is essential to the quality and effectiveness of these services. MTSS is an umbrella term for an approach designed to respond to the needs of all students within a system that integrates, but is not limited to, tiered behavioral supports, and is part of the structure of a comprehensive school-based mental health system. MTSS is a whole school, data driven, prevention-based framework for improving learning and adjustment outcomes for all students through a layered continuum of evidence-based practices and systems. Universally offered Tier 1 services (i.e., services offered to all students within a school system) typically include widespread screening, social-emotional based learning curricula, and prevention-based activities that foster healthy functioning in a positive school climate. Tier 2 services allow for early intervention and targeted support (i.e., for students exhibiting risk factors often associated with potential issues but for whom the issues have not fully manifested), and may include more directed student screening and interventions to reduce the likelihood of issues developing or resolve early difficulty. Tier 3 services are generally for students identified as experiencing mental health difficulties, and may include individual or family/caregiver treatment or other individualized interventions to address the identified mental health challenge.
School-based mental health services
On the Road to Better Youth Mental Health: A Roadmap for School-Based Mental Health Services offers guidance on using a MTSS framework to structure comprehensive and effective mental health services in schools.
Comprehensive School-based mental health services
The National Association of School Psychologists (NASP) has proposed the following model to structure mental health services in schools. While not limited to the traditional “three tiered” model, it represents a comprehensive system of support and provides examples of the continuum of services.
School-employed mental health providers focus on prevention by implementing evidence-based interventions at the school-wide level. At the Tier 1 level, universal interventions should be effective for 80 percent of the student population. Interventions simultaneously work to reduce negative behaviors while building social-emotional competencies and mental wellness. It is important to conceptualize “mental health” as a continuum between mental wellness and mental illness. It is often the role of Tier 1 support to address the promotion of mental wellness. Universal interventions that promote mental wellness include social and emotional learning, mental health education, and behavioral support. According to the National Center on Safe and Supportive Learning Environments, a positive school climate is related to school success, including attendance and achievement. School districts may consider developing a school climate committee to assess perspectives of the current school environment and determine areas in need of improvement at the universal level. The National Center for School Mental Health offers recommendations for best practices in assessing school climate and implementing supports at the Tier 1 level. The Bank Street College of Education Center on Culture, Race & Equity compiled several resources related to equity and culturally responsive practices to help foster a positive school climate. Social and Emotional Learning School-employed mental health providers can collaborate to properly select and implement evidence-based social and emotional learning (SEL) programs that best suit the needs of the district’s culture, climate, and demographics. Research indicates that SEL has a positive impact on student engagement and academic achievement, and the positive impacts are long term. School communities who implement social and emotional learning also experience fewer discipline problems, as well as a decrease in emotional stress. SEL also promotes educational equity and celebrates the talents, interests, and cultural values of all. Establishing benchmarks for SEL promotes student engagement in the learning process. The New York State Education Department (2022) offers guidance on how to align benchmarks to the New York State Social Emotional Learning Goals. The Collaborative for Academic, Social, and Emotional Learning (CASEL) defines the five core competencies of SEL as self-awareness, self-management, social awareness, relationship skills, and responsible decision-making. An environment that promotes mental wellness and builds social-emotional competencies also prepares students to face adversity. While it is not ideal, it is inevitable that children will face negative experiences at some point in their lives. SEL helps students develop coping skills and build resiliency. Building skills in resiliency in a safe and supportive school community allows youth to learn and grow from adverse experiences and face future challenges. To support students in building resiliency, school teams can provide a caring learning environment that encourages healthy habits and fosters academic self-determination and competence. School districts may be at different starting points with regards to their implementation of SEL. School teams may consider visiting CASEL's District Resource Center to examine pertinent research, focus areas, and key activities that consider the unique needs of their school districts. School districts may also access resources from the New York State Education Department (NYSED), including Social Emotional Learning: A Guide to Systemic Whole School Implementation and Social Emotional Learning: Essential for Learning, Essential for Life, which highlight various resources for SEL considering Multi-Tiered System of Supports (MTSS). Additional support and training for school districts can be found at the NYSED Partnership MTSS-I website. The mission of this center is to improve outcomes for all students by building capacity in educational organizations (EOs) to deliver evidence-based practices within a tiered system. The MTSS-I Center will empower education stakeholders, and support teachers and other providers in effective practices for improved students’ results. Mental Health Education All students and staff should be provided with mental health education and information on prevention of specific concerns including, but not limited to suicide prevention, substance use, and stress management. School-employed mental health providers can assist school teams in determining how and when to teach this information, taking into consideration the school culture and developmental level of the students. For example, if it is determined that content will be embedded in the Health curriculum, school-employed mental health providers may collaborate with health teachers to support this instruction on days that specific lessons are taught. School psychologists or other providers can provide workshops or other professional development activities to provide information on common childhood or adolescent mental health issues. School-employed mental health providers should work closely with administrators and faculty to determine the best approach to delivering information on sensitive topics, such as suicide prevention. Suicide prevention is a collaborative effort that requires professional development for all school staff. The Suicide Prevention Center of New York State (SPC-NY) offers a variety of resources to support school districts in educating staff, parents, and students on the warning signs of suicide. School-employed mental health providers may be called upon to share information with staff, parents, and students on how to recognize risk factors and warning signs of suicide or at-risk behaviors, and how to connect the individual to help. A comprehensive resource to help schools develop effective suicide prevention policies and practices, A Guide For Suicide Prevention In New York Schools, is available from SPC-NY and The NYS Office of Mental Health. With a growing number of students impacted by adverse childhood experiences (ACEs), schools need to provide professional development on a trauma-sensitive or trauma-informed approach to education. Professional development on trauma-informed education helps school staff understand how trauma impacts learning and behavior. When teachers and school staff are made aware of the signs of trauma and the significance of behavior changes, students can be connected to a school-employed mental health provider early on, with hopes of mitigating the long-term impact. According to the National Educators Association, adopting a trauma sensitive approach to education creates a safe and nurturing learning environment, which supports students in being physically and mentally ready to learn. Taking a trauma sensitive approach to education can potentially lead to positive outcomes for all students, regardless of their trauma history. This preventative effort promotes school connectedness and a school climate that ensures students are receiving the support they need to be successful. School-employed mental health providers work with other school staff to select a trauma-informed framework that best suits the demographic and mental health needs of their district. The National Center on Safe and Supportive Learning Environments offers a number of resources on how to integrate trauma-informed practices in schools. Behavioral Supports Various interventions can be implemented at the Tier 1 level to promote positive behaviors in the overall school community. At the classroom level, teachers can utilize evidence-based classroom management strategies and consult with school-employed mental health providers as needed. When creating school discipline policy, school-employed mental health providers assist school teams in creating policy that promotes SEL and aligns with the SEL goals of the school. Responsive and restorative discipline policies help students understand the impact of their behavior and work to repair relationships by examining thoughts and feelings about the incident. Restorative Justice is a philosophical and practical approach that focuses on the relationships between all people who make up a community. In the school context, this includes teachers, students, parents, staff, administrators, the board of education, and community members. Restorative Justice encompasses an array of practices that, when implemented in a systemic way, create a culture that is more connected, supportive, and accountable. This results in increased academic achievement, improved school engagement, decreased emotional distress and fewer negative behaviors. NYSED is offering free online restorative leadership training during the Fall of 2023 designed for school building leadership teams committed to implementing a restorative framework in their schools. The NYC Department of Education has published the Restorative Practice Handbook, which was designed as a facilitators guide for staff in conducting restorative practices. Additionally, CASEL offers a variety of resources on restorative practices and SEL alignment. The National School Climate Center refers to school climate as the “quality and character of school life.” This includes both social and physical aspects of the school that can positively promote behavior, school achievement, and the social and emotional development of students. One way to promote a positive school climate is by offering a variety of extra-curricular activities (e.g. clubs, sports, mentoring programs, etc.), which allow students opportunities to develop and maintain a connection to the school community and develop relationships with trusted adults. Participation in extracurricular activities also fosters growth in an area of interest and promotes socialization. School-employed mental health providers, teachers, and administrators can assist students in selecting activities. There may be times that students require additional support from mental health providers to overcome concerns or other barriers to joining extra-curricular activities. School teams, clubs, and other activities can identify and share developmentally appropriate school-wide behavioral expectations that align with the skills taught within the SEL framework. Research indicates that implementing Positive Behavioral Interventions and Supports (PBIS) with fidelity leads to improvements in school climate, social emotional competence, and academic success. The Center on PBIS offers a number of resources including how to implement PBIS following MTSS and resources for special topics (e.g. bullying prevention, students with disabilities, juvenile justice, early childhood, etc.). In line with SEL and creating a positive school climate, school teams should also incorporate interventions that focus on bullying prevention. The Dignity for All Students Act or The Dignity Act (DASA) ensures that all students can learn in a safe and supportive learning environment, free from harassment and discrimination. The New York State Education Department has compiled several resources for school districts related to bullying prevention. The resource Creating a Safe, Supportive, and Affirming School Environment for Transgender and Gender Expansive Students: 2023 Legal Update and Best Practices provides extensive information on how to support transgender and gender expansive (TGE) students, who experience high rates of bullying in school. Data-based Decision Making at Tier 1 School-employed mental health providers collaborate with school staff to determine which students are responding to Tier 1 interventions and identify students who are in need of more support, or Tier 2 interventions. A universal screening process will assist school teams in making these determinations and intervene early. The National Association of School Psychologists (2020) recommends using universal screeners to identify students who display concerns regarding social, emotional, and behavioral functioning. Identification of those who are potentially at risk of developing social and emotional problems allows school-employed mental health providers to intervene early. School-employed mental health providers can examine results to determine if there are trends in school-wide social, emotional, and behavioral functioning. Identifying trends through this data-driven process informs decision-making regarding additional programming to support mental wellness. During the universal screening process, information is gathered from multiple sources, including but not limited to brief rating scales, teacher nomination procedures, and existing behavior data (e.g., disciplinary referrals, attendance records). It is important that the rating scales are vetted to be evidenced-based and developmentally appropriate. Universal screening procedures include those that measure internalizing and externalizing problems, and deficits in social-emotional functioning and academic engagement. School teams can also take a strengths-based approach to identifying components of student wellness and social-emotional competencies. School-employed mental health providers can work with school teams to determine the data they would like to obtain in order to make informed decisions based on the needs of their school community. Factors such as ethical and legal considerations, the screening approach, consent, informants, and data collection and storage procedures will need to be considered. The School Mental Health Collaborative and Ready, Set, Go, Review: Screening for Behavioral Health Risk in Schools are resources that offer guidance on best practices in universal screening procedures.
Tier 1 Mental and Behavioral Health Services
What is Social and Emotional Learning (SEL) The Collaborative for Academic, Social, and Emotional Learning (CASEL) defines social and emotional learning as the process through which all young people and adults acquire and apply the knowledge, skills, and attitudes to: Develop healthy identities Manage emotions and achieve personal and collective goals Feel and show empathy for others Establish and maintain supportive relationships Make responsible and caring decisions For more information, visit www.casel.org.
Components of a Trauma Informed Framework Approaches that focus on the entire school's policies and practices Dedication to a safe school environment Explicit teaching of skills related to resilience and coping Professional development focused on effective discipline, awareness building, and educational strategies (Eklund & Rossen, 2016)
Data Sources for Tier 1 Decision Making Climate surveys Attendance Grades Discipline records Universal screeners (e.g., rating scales, teacher nomination) Anecdotal information regarding individual student experiences Risk factors for and warning signs of psychological distress Data from caregivers Teacher report Self-report data
Examples of Tier 1 Intervention Resources Resources from the New York State Education Department include: Social Emotional Learning: A Guide to Systemic Whole School Implementation Social Emotional Learning: Essential for Learning, Essential for Life Multi-Tiered System of Supports-Integrated The Dignity Act Creating a Safe, Supportive, and Affirming School Environment for Transgender and Gender Expansive Students: 2023 Legal Update and Best Practices New York State Social Emotional Learning Goals Bank Street College of Education Center on Culture, Race & Equity: Provides age- and grade-specific resources on equity and culturally responsive practices Collaborative for Academic, Social, and Emotional Learning (CASEL): Information on the fundamentals of SEL and recommendations for systematic implementation, including The CASEL Guide to Schoolwide Social and Emotional Learning National Association of School Psychologists: Offers a variety of resources related to mental health services and resilience and wellness promotion in schools The National Center on Safe and Supportive Learning Environments: Offers information and technical assistance to states, districts, schools, institutions of higher education, and communities focused on improving school climate and conditions for learning Suicide Prevention Center of New York State (SPC-NY): Comprehensive set of tools, information, and resources to support the effort of suicide prevention, including A Guide for Suicide Prevention in New York Schools Guidance for Trauma Screening in Schools: Provides an overview of the impact of trauma, school-based considerations for screening, and how to link data to interventions in schools Center on PBIS: Resources for implementing a multi-tiered approach to social, emotional, and behavioral support NYC Department of Education: Restorative Practice Handbook: Guide on the basic structures and framework of restorative circles Ready, Set, Go, Review: Screening for Behavioral Health Risk in Schools: Guidance and resources on proper screening procedures in schools
Tier 2 Mental and Behavioral Health Services
Data-based Decision Making The need for Tier 2 supports is best determined using a data-based decision-making protocol which is systemic and equitable. Such a protocol can be part of the school’s Response to Intervention (RTI)/Multi-tiered System of Supports (MTSS) team process, or made through a formal referral process from teachers, parents, or self-referrals. Decision making regarding Tier 2 supports involves examining data from various sources through the Tier 1 universal screening process. Tier 2 mental health services are implemented by school-employed mental health providers to students experiencing distress, impaired functioning, or who are at risk for a given problem or concern. Impact of the COVID-19 pandemic should also be considered, such as food, financial, and housing instability, as well as the loss of loved ones. Groups who have been historically marginalized, such as Black, Indigenous, or People of Color (BIPOC), or those identifying as members of the LGTBTQ+ community are at higher risk for depression and suicidal ideation, and therefore must also be considered. It is important to note that BIPOC individuals or those identifying as LGBTQ+ experience higher levels of mental distress due to the unique challenges resulting from societal attitudes, policies, and practices. Therefore, it is critical for schools to create a climate and support to address these unique factors. Group Counseling and Other Mental Health Interventions Tier 2 mental health counseling support groups to address specific issues often include Trauma, Anxiety, Depression, Emotional Coping Skills, Social Skills Building, Improving Self-Esteem, Emotional and Behavioral Self-Regulation, Changing Families, Bereavement, Anger Management, and Behavioral Issues. The length and frequency of counseling groups is determined by the intensity of the presenting problem and impact on the student’s level of functioning. Dr. Christopher Liang and Kelsey Gaier from Lehigh University created the Trauma-Responsive Multi-Tiered System of Supports (MTSS) Toolkit For Educators. While the toolkit in general is an excellent resource for educators, the section on Tier 2 Supports provides guidance on various group interventions. School teams may consider implementing these Tier 2 interventions through counseling support groups or a “lunch bunch” group. "Lunch bunches” are used to develop relationships and establish connectedness with students. In a lunch bunch, selected students meet in a small group with school-employed mental health providers to promote specific social-emotional and behavioral goals. Brief, periodic “check ins” are also a Tier 2 intervention that are a direct service to a student. These consultations or “check ins” provide an opportunity to gauge a student’s mental health status. Consultations allow the school-employed mental health provider to assess a student’s current level of functioning and progress toward goals. Consults can vary in length from a few minutes to the length of a counseling session, depending upon the student’s needs. Consults can be provided to students individually or in small groups. Peace Rooms or calming rooms are another Tier 2 intervention that are effective in helping students learn and use coping skills. A Peace Room is a relaxing place staffed by school employees trained in counseling and mindfulness. Students who are feeling dysregulated or in need of support can access the Peace Room to speak with an adult and/or to use mindfulness strategies to calm and process their emotions. Peace Rooms serve a dual purpose: to help students regulate and process emotions while learning coping and mindfulness skills that they can eventually employ independently. In addition to targeted interventions provided by school-based mental health providers, Tier 2 interventions can also include service delivery from a broader, building level model utilizing school faculty and staff as “caring adults” to provide support via student mentoring or Check-In/ Check-Out programs. Check-In/Check-Out (CICO) is designed to give students a more tailored intervention and allow them to meet behavioral goals that can lead them back to Tier 1 (Strawhun & Peterson, 2013). A student paired with a caring adult can establish daily or weekly goals with the adult and touch base with the adult throughout the school day to get feedback and discuss progress. CICO provides structure for the student, regular feedback, and improves academic and emotional functioning. Student participation in such programs should be determined utilizing a data-based decision-making protocol, and use specific criteria to determine adult-student pairings. Tier 2 mental and behavioral health interventions also include engaging with families. Parent consultation is a Tier 2 intervention that aids in addressing specific student mental and behavioral health issues. While it may be an indirect intervention, the provision of information, trainings, and referral resources is an important part of holistically addressing student needs, and can help contribute to the efficacy of direct Tier 2 student interventions. Teacher consultation is an indirect Tier 2 intervention that can be effective in addressing student needs in the classroom. School-employed mental health professionals consulting with teachers regarding topics such as student mental health issues, trauma-informed practices, and behavioral interventions provide valuable information and training to teachers working directly with students. Consultation provides teachers with the skills needed to support students, potentially de-escalate situations, and create caring classroom environments. Is the student responding to Tier 2 services? Direct Tier 2 interventions should be progress monitored to gauge a student’s response to the intervention. If progress monitoring indicates a student is not responding appropriately to Tier 2 support, then Tier 3 supports should be considered. Conversely, if progress monitoring indicates the student has responded well to the Tier 2 support then it is possible the intervention is no longer needed. When implementing Tier 2 interventions, it is important to establish goals and expected outcomes, and to progress monitor to assess response to the Tier 2 intervention. Tools for Monitoring Student Progress for Behavioral Interventions are available online, or can be developed with input from school-employed mental health providers at the school level.
Tier 2 mental and behavioral health services can be both direct and indirect interventions. They provide support to targeted groups of students who are beginning to display signs of behavioral and/or emotional challenges or who need more support due to other risk factors. Such risk factors may include issues related to a student’s home or community environment, health or other biological issues, or emerging mental health issues. In conjunction with Tier 1 universal and prevention programs, Tier 2 supports are selective and geared toward strengthening skills, competencies, and reducing risk in students who are identified as in need of a higher level of support and intervention. The goal of Tier 2 interventions is to address students’ needs and respond in a specific way in order to mitigate the issue, as well as prevent it from becoming worse. It is a proactive means of supporting students’ mental and behavioral health needs. However, it is imperative that Tier 1 interventions and supports are implemented systemically and with fidelity as part of a Multi-Tiered System of Supports.
Data Sources for Tier 2 Decision Making Data from Tier 1 programs Attendance Grades Discipline records Previous support at school Pre-existing conditions Behavioral, social, or emotional concerns Data from teachers, caregivers
Tier 2 mental and behavioral health interventions require the training and expertise of mental health professionals. It is imperative that schools are adequately staffed at the recommended ratios for each profession: school psychologists, school social workers, school counselors, and school nurses. Appropriate staffing levels ensure that Tier 2 mental and behavioral health interventions are implemented with consistency and integrity, and thus efficacy can be assessed.
General Features of Tier 2 Mental Health Service Include: Evidence-based interventions are delivered directly in small groups and are provided by specialized personnel (e.g., school psychologists, school social workers). School personnel monitor student progress regularly Building level programs provide support to specific students via mentoring, consultation, & therapeutic spaces Family engagement to provide indirect student support
Examples of Tier 2 Intervention Guides Positive Behavior Interventions & Supports Tier 2 Lehigh University Trauma Responsive MTSS Toolkit - Tier 2 National Center for School Safety Tier 2 Interventions Institute of Education Sciences Menu of Trauma-Informed Programs for Schools University of Maryland School of Medicine School Mental Health Quality Guide
Examples of Tier 2 Intervention Resources Cognitive-Behavioral Intervention for Trauma in Schools: A cognitive-behavioral school-based group and individual intervention program for grades 5-12 that addresses behavioral health issues and improves functioning The Bounce Back Program: A cognitive-behavioral school-based group and individual intervention program for grades K-5 that addresses behavioral health issues and improves functioning Coping Cat Workbook: CBT workbook to reduce anxiety and promote coping skills Anger and Aggression Workbook: A resource to help 7-12 year old students develop anger management skills Check In/Check Out: A mentoring program that pairs students with an adult in school, providing additional support for students to meet their goals socially, emotionally, and/or academically Banana Splits: A school-based children's group program for students who have experienced parental divorce or death / Banana Splits (2009); Gonagle, E., & Raymond, V. Interact. Peace Room: A dedicated, safe, and neutral space in a school building for students to work through difficult emotions and challenging situations with the help of a restorative practice practitioner, mental health professional, teacher, or mentor
Effective Tier 1 and Tier 2 practices provide the foundation upon which viable and sustainable Tier 3 interventions may be built. When prevention and early interventions do not meet students’ needs, other interventions should be used. Intensive and individualized interventions should be linked with the system of care principles, where “wraparound” or coordination of school-based services with community support are facilitated to meet the needs of students and families. However, it is important to recognize that many communities lack mental health resources for children and families. This includes a lack of mental health professionals who work with youth, particularly younger children. This gap in mental health professionals needs to be addressed in order to increase access to services within the community.
Tier 3 Mental and Behavioral Health Services
Tier 3 or indicated services are for students who already display a mental health concern or problem. In providing services to students with intensive needs, school teams need to apply a culturally responsive and equity-focused lens to their identification and intervention processes. Cultural norms and expectations for emotional responses, expression, and behavior vary widely, as do norms for help-seeking and community support. Current and historical context for emotions and behaviors must be considered. Student’s individual and cultural strengths must be a significant point of emphasis in any intervention plan. While many students may display a range of emotional and behavioral challenges over time, determining which students need Tier 3 intensive support should be based upon data collected by the school team. To avoid overidentification of students requiring additional support, more intensive services should not occur until after Tier 1 interventions have been provided to all students for a period of time and, ideally, Tier 2 strategies have been implemented. Individual needs may be identified via monitoring data from Tier 1 and Tier 2 interventions, as well as broader data sources such as attendance, grades, and discipline records. Anecdotal information regarding individual student experiences, including risk factors for and warning signs of psychological distress must also be considered. Data from caregivers and self-report data from older students will also be valuable. It is important to rely on patterns of data from multiple sources and settings, rather than one data point alone, when identifying students in need of intensive, individualized interventions at the Tier 3 level. Comprehensive school mental health systems rely on a foundation of educators and school-employed mental health professionals (e.g. school psychologists, school counselors, school social workers), in partnership with community health and mental health professionals. States, districts, and schools often grapple with how to strategically staff a full continuum of mental health supports and services, sometimes exclusively relying on either schools or community partners. This strategy fails to leverage the strengths and resources of each system (education and health/behavioral health) and may lead to siloed and fragmented supports. In addition to collaborations with community mental health providers and families, schools can develop collaborations with the faith community, law enforcement, physical health care providers, community mental health and substance treatment providers, local businesses, and government agencies. These collaborations can be utilized to help prevent mental health issues among children and adolescents in schools, better identify and support children and adolescents with mental disorders, and make referrals to needed treatment for mental health issues. Although the school system plays an integral role in ensuring the sound mental health of its students, a comprehensive community approach is essential to the successful expansion of school-based mental health systems. Effective collaboration between school-employed and community mental health partners broadens the availability of support and enhances access to mental health care. The roles and responsibilities of school and community partners will differ based on unique resources and needs of school districts and the local community. However, it is critical for schools to use collaboration with community resources to supplement the services of those offered by school-employed mental health professionals and not supplant the services provided by school employees with those of community professionals. School community partnerships can play a crucial role in addressing children's mental health issues by combining the resources and expertise of various stakeholders. Here are some examples of school community partnerships that can support children's mental health: Community Mental Health Centers: Collaborating with local mental health centers can provide schools with access to mental health professionals who can offer assessments, therapy, and other specialized services. These centers can also provide training for school staff on mental health awareness and intervention strategies. Nonprofit Organizations: Partnering with nonprofit organizations focused on children's mental health can provide additional resources and support. These organizations often offer counseling services, educational programs, and advocacy initiatives. They may also collaborate with schools to implement evidence-based mental health programs and initiatives. Universities and Research Institutions: Collaborating with universities and research institutions can bring expertise in child psychology, counseling, and mental health research to schools. These partnerships can involve joint research projects, training opportunities for school staff, and the implementation of evidence-based practices within the school setting. Local Health Departments: Engaging with local health departments can help schools connect with community health resources, including mental health services. Health departments often have programs focused on child and adolescent mental health, and they can provide guidance, training, and support to schools in addressing mental health issues. Parent and Family Organizations: Partnering with parent and family organizations, such as parent-teacher associations (PTAs) or parent support groups, can enhance efforts to address children's mental health. These organizations can help raise awareness, advocate for mental health services and resources, and facilitate parent engagement in mental health initiatives. Faith-Based Organizations: Faith-based organizations can contribute to children's mental health support through counseling services, mentorship programs, and community outreach. Schools can collaborate with these organizations to provide additional resources and support for children and families. Local Businesses and Foundations: Engaging local businesses and foundations in supporting children's mental health initiatives can lead to increased resources and funding. They can provide financial support for mental health programs, sponsor awareness campaigns, or offer in-kind services and resources to schools. It's important for schools to establish formal partnerships and maintain ongoing communication with these community stakeholders to ensure effective collaboration and coordination in addressing children's mental health issues. Each partnership can be tailored to the specific needs and resources available within the community. Guidance for creating partnerships between school districts and community partners has been provided by The New York State Office of Mental Health and the National Association of School Psychologists. Examples of Tier 3 mental health interventions in schools include: Functional Behavioral Assessment (FBA) and Behavior Intervention Plan (BIP): For children with interfering behaviors that significantly impact their functioning in school, a comprehensive assessment known as a FBA may be conducted. Based on the assessment, a Behavior Intervention Plan (BIP) may be developed to promote positive behavior change through targeted interventions, based on the function(s) of the interfering behavior. Referral for special education or Section 504 services: For students suspected of having an “educational disability” or a disabling condition that substantially impacts one or more areas of their life, including school, are entitled to an individualized evaluation to determine the need for specialized services and/or school-based supports. It is important to note that within some literature and practice across the US, special education is considered Tier 3, but may also be in other variations of tiered supports (e.g., tier 3+, tier 4). Individual Counseling/Therapy: Students receive one-on-one counseling or therapy sessions to address their specific mental health challenges. This intervention focuses on developing coping strategies, improving emotional regulation, and addressing specific mental health diagnoses. Services can be provided by school-employed mental health professionals (e.g., school psychologists, school social workers, school counselors) or community professionals based upon cooperative agreements with school districts. Group Therapy: Students with similar mental health concerns may participate in group therapy sessions facilitated by school-employed or community mental health professionals. Group therapy can provide a supportive environment for students to share experiences, learn from each other, and develop social skills. Crisis Intervention: This intervention is designed to provide immediate support to students experiencing a mental health crisis, such as a severe emotional event, self-harm, or suicidal ideation. School-employed mental health professionals help manage and de-escalate the crisis while ensuring the safety and well-being of the student. Necessary referrals to community providers are made based upon individual needs. Psychiatric Consultation: With parental consent, collaboration between mental health professionals and psychiatrists can provide comprehensive care for students with complex mental health needs. Psychiatrists assess, diagnose, and prescribe medication if necessary, while mental health professionals continue to provide therapy and support. Referrals to Community Resources: Mental health professionals in schools can assist in connecting students and their families to external resources, such as community mental health centers, outpatient programs, or specialized therapists who can offer more specialized or long-term care. Collaborative Consultation and Collaboration: School-employed and community mental health professionals can work closely with teachers, parents, and other school staff to develop collaborative strategies and interventions to support children with complex mental health needs. This may involve regular meetings, case conferences, and shared decision-making to ensure a coordinated and holistic approach to the child's mental health care. Social Skills Training and Groups: Children struggling with social skills deficits or difficulties in peer relationships may benefit from social skills training or participation in social skills groups. These interventions focus on improving communication, problem-solving, empathy, and conflict resolution skills, helping children develop positive social interactions and relationships. (May also be a Tier 2 intervention) School-Based Support Groups: Support groups provide children with a safe and supportive space to connect with peers who may share similar mental health concerns. These groups can address various topics, such as grief and loss, self-esteem, anxiety management, or coping with family transitions. (May also be a Tier 2 intervention)
Data Sources for Tier 3 Decision Making Data from Tier 1 and Tier 2 interventions Attendance Grades Discipline records Anecdotal information regarding individual student experiences Risk factors for and warning signs of psychological distress Data from caregivers Self-report data
General Features of Tier 3 Mental Health Service Include: Evidence-based interventions are individualized and are provided by specialized personnel (e.g., school psychologists, school social workers). As needed, functional behavioral assessments are conducted by school psychologists to determine the environmental factors that are maintaining the behavior. Such data are used to create multisystemic interventions across a range of environments, including school, home, and community. Wraparound support that involves collaboration between school and community service providers might be needed. School personnel monitor student progress frequently, with measures specifically matched to the student's individual goals.
Examples of Tier 3 Intervention Resources National Association of School Psychologists (NASP): NASP provides guidance and resources for implementing tiered mental health services in schools. Their website offers articles, webinars, and toolkits for school professionals National Center for School Mental Health (NCSMH): leads innovation in comprehensive school mental health systems designing and evaluating cutting-edge programs, practices and policies to advance high impact outcomes for youth, families, educators and communities What Works Clearinghouse (WWC): The WWC has been a central and trusted source of scientific evidence on education programs, products, practices, and policies. They review the research, determine which studies meet rigorous standards, and summarize the findings. They focus on high-quality research to answer the question “what works in education?” Blueprints for Healthy Youth Development: A project within the Institute of Behavioral Science at the University of Colorado Boulder. They identify, recommend, and disseminate programs for youth, families and communities that, based on scientific evaluations, have strong evidence of effectiveness, Selecting Evidence-Based Programs: National Resource Center for Mental Health Promotion and Youth Violence Prevention Guide
Potential Roadblock
Supportive Solutions to Overcome Roadblocks
Obtaining appropriate and sustainable funding for staffing school-employed mental health providers
Mental Health Recover from COVID School Program (RECOVS) Grant Learning Loss RECOVS Grant. Project AWARE Grants Medicaid funded School Supportive Health Programs Cooperative Agreements for School-Based Trauma-Informed Support Services (TISS) and Mental Health Care for Children and Youth Bipartisan Safer Communities Act Greenlights Grant Initiative
Mental health staff engaged in other activities (e.g., special education process)
Administrators need to collaborate with school-employed mental health providers and school teams to discuss recommended staffing ratios (e.g., school psychologists, 500:1; school social workers, 250:1) Utilize grant funding identified above to ensure appropriate ratios of school-employed mental health providers
Potential Roadblocks to Implementation
Providing school-based mental and behavioral services following the MTSS model allows students to access much needed services in a supportive environment. The following are suggestions to mitigate potential roadblocks that may arise during the implementation process:
Obtaining appropriate resources and staff development related to mental health services in schools
MHANYS School Mental Health Resources and Training Center Training and Support from the New York State Education Department: Office of Special Education
The perception that school-based mental health providers should not provide these services
It is important to note that services at all three levels are considered mental and behavioral health services, not just intensive services at Tier 3. It is appropriate for school psychologists and other school-based providers to engage in these services. School Psychologists, School Social Workers, and School Counselors all have national practice models that identify them as qualified to provide mental and behavioral health services based upon their expertise and training.
Gaining buy-in from staff, parents, and students
Reconsider “top down” approaches in selecting and implementing programs; include representatives from various departments in selecting the SEL program/approach to discuss feasibility Establish an ongoing district-wide committee consisting of staff members in various roles to discuss mental and behavioral health initiatives in the district Focus on research-based programs that demonstrate effectiveness Educate staff and parents about the impact of mental wellness on student achievement
Time
Educate staff and parents on how implementation of services saves time in the long-run; following the MTSS model ensures that we are serving all students and identifying those who need more support Spread out SEL lessons or integrate lessons into academic instruction Identify a program that has lesson plans already written Dedicate a period in the schedule to allow for implementation
Stress/workload/burnout
Focus on wellness and authentic self-care Create/promote a caring environment for staff Recognize that morale is an important component of a positive work environment Team building, celebrations, recognitions, and mentoring help improve staff morale Provide meaningful professional development based on staff interest and needs assessments
Lack of community resources for children’s mental health services
Increase mental health workforce and access to services through licensing school psychologists to provide services in the schools AND community Use collaborative agreements with local hospitals and the NYS OMH local agencies to supplement, not supplant school-based services
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References
Please cite this document as: New York Association of School Psychologists. (2023). On the road to better youth mental health: A roadmap for school-based mental health services. Albany, NY: Author.