MENTAL HEALTH SCREENING IN SCHOOLS
Fourth Edition: Kelsey Quest and Anna Pozzatti (2016)
Third Edition: Cara Macchia and Kitty Chen (2014)
Second Edition: Barbara Bari and Natasha Williams (2012)
First Edition: Luke Erichsen and Susan Galford (2011) (Click on the authors of the first edition to see the initial edition)




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National Children's Mental Health Awareness Day is a key strategy of the Caring for Every Child's Mental Health Campaign, which is part of the Public Awareness and Support Strategic Initiative by the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health & Services. The effort seeks to raise awareness about the importance of children's mental health and that positive mental health is essential to a child's healthy development from birth[1] .









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Need for Mental Health Services:

An alarming number of children with treatable mental health problems are not receiving the help they need to succeed personally and academically. Reviews of epidemiological studies indicate that some 16-22% of children and adolescents have a diagnosable mental disorder, but only one out of five of these children receives mental health services. Moreover, the large majority of students who do receive treatment find it within the school setting.[2]
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Approximately 1 of 5 children has a mental disorder
Children's socioemotional well-being is essential to their academic success. While academic concerns are often at the forefront of policy initiatives, the role of mental health on academic outcomes is incontestable. Longitudinal research has shown that both internalizing and externalizing symptomatology may predict later poor academic achievement and/or negative life outcomes.[3] Students will struggle with academic success if they struggle with debilitating anxiety, feel too depressed to handle the stressors of school life, or lack the self-regulation skills to manage hyperactive or aggressive tendencies.



The New Freedom Commission report provides recommendations for changing and improving mental health services[4] :
  • Promote the mental health of young children.
  • Improve and expand school mental health program.
  • Screen for co-occuring mental and substance disorders and link with integrated treatment strategies.
  • Screen for mental disorders in primary health care, across the lifespan, and connect to treatment and supports.
The following videos give us some further insight into the need to address mental health problems in children and adolescents.


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Percent of U.S. high schools that universally screen (from Baker, 2008)
**H. R. 751**Purpose: To amend the Public Health Service Act to revise and extend projects relating to children and violence to provide access to school-based comprehensivemental health programs[5] .
In February 2011, Rep. Grace F. Napolitano introduced HR 751, the Mental Health in Schools Act, to the 112th Congress in an effort to explain the importance of increasing mental health services for youth. The Mental Health in Schools Act would provide funding for public schools across the country to partner with local mental health professionals to establish on-site mental health care services for students. The Mental Health in Schools Act would create a competitive grant program which would allow the receiving school districts to hire mental health professionals. By having qualified professionals working on-site in the schools, parents and administrators will be better able to detect and prevent mental illness.The Mental Health in Schools Act will help students by:
  • Helping provide professional help for the 1 out of 5 youth who suffer from some form of mental illness.
  • Addressing mental health problems when students are young, instead of waiting until they have drifted into drug use, crime, depression, or suicide.
  • Keeping costs low, because mental health costs are very little compared to the costs placed on social services and the prison system when mental health is neglected.
  • Saving lives, by funding school employed or community employed mental health professionals who help prevent suicide by identifying at-risk youth and counseling students before their problems spiral out of control.
Addiional Details on the Mental Health in Schools Act:The Mental Health in Schools Act would provide $200,000,000 in competitive grants each year for a total of $1 million each. It would expand the scope of the Safe Schools/Healthy Students Program by providing on-site licensed mental health professionals in schools across the country. Funding would be distributed by the Substance Abuse and Mental Health Services Administration (SAMHSA), which will set guidelines and measure the outcomes of the funded programs.














Arguments Against Mental Health Screening:

Mental health screening in schools has attracted its share of controversy. Some view the process as an invasion of family privacy,an unnecessary intrusion of the school system into an area it should not be concerned with, or a thinly veiled screen for pushing medication on youth. This anti-mental health screening video, produced by an anti-psychiatry organization, features the Columbia TeenScreen program. TeenScreen's website specifically notes that its voluntary program "does not receive support or funding from the pharmaceutical industry and does not advocate for any specific treatment." Weist and his colleagues (2008) [3] argue that this misconception results from the false belief that screening programs are mandatory; rather, all programs require active informed consent. Levitt and her colleagues (2007) [4] reiterate the fact that schools must work hard to engage all families in providing support to children, because informed consent may be hardest to obtain from students at greatest risk.
[[http://www.jpands.org/vol11no3/lehrman.pdf|"The Dangers of Mental Health Screening" by Nathaniel S. Lehrman, M.D.[6] This article provides a nice accompaniment to the above YouTube video. In this piece, Lehrman discusses the drawbacks to early mental health screening ranging from the stigma suffered by children identified with mental illness to a lifelong dependence on medication.



Clinical Model vs. Public Health Model:
Doll and Cummings' (2008) discussion[7] of mental health services illustrates the distinction between traditional referral-based systems and population-based services by use of analogy. forest.jpgOne can nurture a single tree showing signs of distress back to health, or one can work to keep the entire forest healthy. Both the single tree and the forest require sustenance, and either will be susceptible to problems if deprived of nutrients. While one caretaker may be able to provide extensive attention to a single ailing tree, those responsible for health of the forest must use different, highly efficient methods to accomplish their task. balance.PNGDoll and Cummings then note that the analogy falls apart at this level, because while a few trees may be sacrificed in a forest, every child's needs must be considered in the implementation of population-based services.




School psychology has traditionally utilized a clinical model for the provision of mental health services, where students receive services when they clearly cannot benefit from regular educational programming. At this point, the struggling student may be assessed for eligibility for special education services, or perhaps in the case of behavior problems, the child may be the subject of school discipline. This model has been criticized as a "wait-to-fail" approach: the focus is on intervention for individual needs rather than prevention of problems in the entire population. The public health literature has long advocated a service delivery model that addresses the needs of everyone, primarily through prevention of disease and promotion of healthy practices (Doll & Cummings, 2008). NASP's Blueprint III (2006) also endorses the application of a prevention-based model and stresses the importance of universal services, or "systems-level programs directed at all and designed to meet the academic and social-emotional needs of the vast majority of students."Financial considerations: Others have noted that transitioning to a public health model of mental health service delivery makes long-term financial sense.[8] Treating mental health problems is expensive; for severe cases in the school setting, these costs may involve special education services.money.jpg Promoting mental health and preventing problems may require an up-front investment but clearly pays out over time. The Minnesota Mental Health Working Group's (2008) report suggests that immediate funding may need to increase to implement such a system to avoid neglecting current treatment needs, which are typically underfunded.







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Mental Health Screening Update- Intervention in an RTI Model:

Psychosis devastates 3.4% of the population over a lifetime, with 80% of first time presentations occurring in youth between the ages of 16 and 30 years. Developing an early detection, early prevention protocol has become of paramount importance in countries such as Great Britain, Canada, Australia, and Scandinavia (Lester, 2009). Shockingly, a 2002 study by Kataoka et. al. revealed that 80% of children between the ages of six and seventeen who were in need of mental health services were not receiving care. The same study indicated that African American, Latino and children of uninsured families were the least likely to receive mental health services (Kataoka, 2002).[9] A need clearly exists for a new approach to school-based mental health services that meets the needs of all students. At present, school psychology is "operating under a 'Refer-Test-Place model of service delivery" often providing services only for the students at the highest risk (Dowdy, 2010). [10] Dowdy further asserts that while this traditional model is "well-intentioned" it remains doubtful that practicing mental health screening at the individual level will yield positive results within the larger whole school population. "Education and Mental Health integration will be advanced when the goal of mental health includes the healthy functioning of students, and the goal of effective schools includes the healthy functioning of students"(Atkins, 2009). [11] In order for this reciprocal change to occur, however, a new mental health framework will need to be adopted that changing the conceptualization of school mental health cases. The educational leaders and researchers have advocated the adoption of the Response to Intervention (RTI) three-tiered model of system delivery as a framework for providing mental health screening.[12] rti_triangle.PNGRTI was developed "in order to identify, support, and monitor" the progress of struggling, or "at-risk" students to meet age/grade level "learning expectations (Hulett, 2009). [13] Bender (2007)[14] further asserts that "Response to intervention is, simply put, a process of implementing high-quality, scientifically validated instructional practices based on learner needs, monitoring students; progress, and adjusting instruction based on the student's response". RTI involves the use of data to identify needs and inform evidence-based intervention and instruction at varying levels of intensity. When applied to mental health issues, the model assumes that all students are receiving a quality socioemotional "curriculum." This core instruction forms Tier I (universal level) of the model. Theoretically, a school with a Positive Behavior Support (PBS) system in place should be working with all students at a school wide level toward building socioemotional competencies. Assessments should be conducted at a minimum frequency of three times per year. School-wide mental health screening at the first tier of RTI would allow schools to identify students not responding adequately to a population-based intervention, and would allow the school mental health practitioners to then place these "at-risk" students in smaller groups at the Tier 2 level where they would then receive "more prescriptive, targeted interventions" Student progress in Tier 2 should be more frequently and closely monitored, occurring with a minimum frequency of one assessment per month (Hulett, 2009). [15] A documented lack of progress at the second tier would necessitate placement of the student into the third tier at which time a formal special education referral would be made. Interventions at this level are individualized and intensive in nature, necessitating bi-weekly monitoring of student progress (Hulett, 2009). [16] How does a school identify students in need? Because the problem-solving model requires universal assessment at the Tier I level, schools need a way to identify students from the entire population who may be at risk for socioemotional problems or already are experiencing difficulty. Demands on time and money mandate that assessment strategies efficiently use available resources. Strategies which require a great amount of time or expense to administer and score are likely to be seen by decision makers as impractical. Baker (2008) discusses approaches to identification of students:
  • Multistage screening. This method involves surveying all students using some type of assessment measure for socioemotional problems. Those meeting predetermined cutoff scores are then further assessed to determine the extent of the problem and match severity of problem with intervention. It is important that the universal screener be brief. For example, the Strengths and Difficulties Questionnaire (SDQ) is only 20 questions but provides an excellent portrait of emotional distress.[17] Levitt, Saka, Romanelli, & Hoagwood (2007) investigated the various measures feasible to use in a school setting and identified a number of reliable scales for many common mental health problems that may be used at each tier level. The SSBD (discussed below) incorporates multistage screening.
  • Identify risk, resilience, and/or protective factors for students. These approaches take a more ecological perspective to school mental health problems, seeking to understand the various influences affecting children. For example, experiencing bullying is a risk factor for poor school outcomes; students may be given a brief self-report form to determine their level of exposure to bullying, which can then be linked to intervention. Another example, ClassMaps, involves student self-report of aspects of resilience. Data are combined at the class level, and a classroom intervention is then designed and implemented.
  • The Systematic Screening for Behavior Disorders (SSBD) is a behavior screening tool used to identify behavior disorders in Systematic_Screening_Flowchart.pngelementary-aged students. The SSBD process includes using a three-stage, multi-gating mass screening system. Within the first stage of the SSBD the classroom teacher systematically ranks all of his/her students according to externalizing or internalizing behavior profiles. During the second stage, the three highest ranking students from the externalizing and internalizing dimensions are then further evaluated by the classroom teacher using two rating scales. The third stage of the SSBD consists of having students identified during the second stage participating in further evaluation by another school professional. The other school professional evaluates the student by using structured observation and recording procedures in the structured and unstructured settings. Individuals who exceed the cutoff scores indicated within the third stage are referred to school-wide child assistance teams.[18] For a graphic representation of the SSBD process, see this flow chart retrieved from the website of The Southeastern Regional Education Service Center. A Screening Procedure Checklist for school leadership implementing systematic screening is also available.
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School-Wide Screenings for Suicide and Depression



teen-suicide.jpgUniversal screeners are recommended when a condition causes significant deaths and can easily be treated (Horowitz, Ballard, & Pao, 2009) [19] . Considering over 1 million adolescents and children attempt suicide each year and a majority of those individuals have treatable conditions such as depression, it is critical that as schools we screen the entire school population to prevent suicide. Effective screeners are brief and easy to administer to an entire population and identify those who are at risk for the condition. Once students are identified, more detailed assessments should be administered. We have provided a list of universal screeners for depression or suicide.

Screening Tool

What does it measure?

Length

Who Completes it?

Age Group

TeenScreen Tool [20]
Pediatric Symptom Checklist for Youth (PSC-Y)

Patient Health Questionnaire Modified for Teens (PHQ-9 Modified)
Risk Factors for Suicide
  • Depression
  • Thoughts of Suicide
  • Suicide Attempts
  • Anxiety
  • Substance Abuse
36-item

13-item
Student
Adolescents
BASC-2[21]
Behavioral and Emotional Screening System Student Self-Report Form (BESS)
  • Inattention/hyperactivity
  • Internalizing problems
  • School problems
  • Personal adjustment
30-item
Student
Grades 3-12
Social Emotional Health Survey (SEHS) [22]
  • Belief-in-Self
  • Belief-in-Others
  • Emotional Competence
  • Engaged Living
36-item
Student
Grade 4- Higher Education
Modified Depression Scale (MDS) [23]
  • The frequency of depressive symptoms
6-item
Student
Adolescent
Strengths and Difficulties Questionnaire (SDQ) [24]
  • Prosocial Behavior and psychopathology
    • Emotional symptoms
    • Conduct problems
    • Hyperactivity/ Inattention
    • Peer relationship problems
    • Prosocial behavior
25-item
StudentParent
Teacher
Ages 3-16
Systematic Screening for Behavior Disorders [25]
Behavior disorders
N/A
Teacher
Elementary Age Student
Columbia Suicide Screen [26]
  • Lifetime suicide attempts
  • Suicide attempts
  • Suicidal ideation
  • Negative mood
  • Substance abuse issues
11-item
Student
Adolescents
Suicide Risk Screen[27]
Risk for suicide
20-item
Student
Adolescents





Mental Health Screening and Assessment Tools

Definition: Screening tools are "instruments designed to identify children and adolescents who are at-risk of having mental health problems or concerns and/or those who would most benefit from a more in-depth assessment" (Williams, 2008).[28]

A Baker's Dozen--Links to Useful Mental Health Screening Sites___
  1. www.mentalhealthscreening.org
  2. mental-health.jpgSMH Online Screening Program
  3. www.zerotothree.org
  4. Downloadable Screening Tools
  5. Standard Health Assessment Tools for Military with Deployment Issues
  6. Quick Depression Screen
  7. Screening Tool for Mental Health in Clients with HIV
  8. MHST--Mental Health Screening Tool
  9. Mass. General Hospital Table of All Screening Tools & Rating Scales
  10. Naitonal Council for Community Behavioral Healthcare
  11. Teen Mental Health Screens (Downloadable)
  12. Psychological Assessment, Testing, and Practice Resources for Psychologists
  13. National Early Childhood Technical Assistance Center--A very comprehensive list of screening tools, uses, and interpretations___




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  1. ^ Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). Caring for Every Child's Mental Health. Retrieved February 29, 2008, from http://www.samhsa.gov/children/
  2. ^ Hoagwood, K., & Johnson, J. (2003). School psychology: a public health framework I: From evidence-based practices to evidence-based policies. Journal of School Psychology, 41, 3-21.
  3. ^ Masten, A. S., Roisman, G. I., Long, J. D., Burt, K. B., Obradović, J., Riley, J. R., & ... Tellegen, A. (2005). Developmental cascades: Linking academic achievement and externalizing and internalizing symptoms over 20 years. Developmental Psychology, 41(5), 733-746.

    Bardone, A. M., Moffitt, T. E., Caspi, A., Dickson, N., & Silva, P. A. (1996). Adult mental health and social outcomes of adolescent girls with depression and conduct disorder. Development and Psychopathology, 8(4), 811-829.
  4. ^


    New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003.
  5. ^


    H.R. 751--112th Congress: Mental Health in Schools Act of 2011. (2011). In GovTrack.us (database of federal legislation). Retrieved February 1, 2012, from http://www.govtrack.us/congress/bill.xpd?bill=h112-751&tab=summary
  6. ^ ]]
    Lehrman, N. S. (2006). The dangers of mental health screening. Journal of American Physicians and Surgeons, 11(3), 80-82.
  7. ^ Doll, B. & Cummings, J. A. (2008). Why population-based services are essential for school mental health, and how to make them happen in your school. In B. Doll & J. A. Cummings (Eds.), Transforming school mental health services: Population-based approaches to promoting the competency and wellness of children. Thousand Oaks: CA: Corwin Press / National Association of School Psychologists.
  8. ^ Minnesota Department of Health Infant, Child, and Adolescent Mental Health Working Group (2008) report
  9. ^ Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among u.s. children: variation by ethnicity and insurance status.American Journal of Psychiatry, 159, 1548-1555.
  10. ^ Dowdy, E., Ritchey, K., & Kamphaus, R. W. (2010). School based screening: a population-based approach to inform and monitor children's mental health needs. School Mental Health, 2(4), 166-176. doi: 10.1007/s12310-010-9036-3
  11. ^ Atkins, M. S., Hoagwood, K. E., Kutash, K., & Seidman, E. (2010). Toward the integration of education and mental health in schools. Administration and Policy in Mental Health and Mental Health Services Research, 37(1-2), 40-47. doi: 10.1007/s10488-010-0299-7
  12. ^ Martinez, R. S., & Nellis, L. M. (2008). Response to intervention: A school-wide approach for promoting academic wellness for all students. In B. Doll & J. A. Cummings (Eds.), Transforming school mental health services: Population-based approaches to promoting the competency and wellness of children. Thousand Oaks: CA: Corwin Press / National Association of School Psychologists.

    See also Doll & Cummings (2008) and NASP Blueprint III
  13. ^ Hulett, K. E. (2009). Legal aspects of special education. Upper Saddle River, NJ: Pearson Education, Inc.
  14. ^ Bender, W., & Shores, C. (2007). Response to intervention: a practical guide for every teacher. Thousand Oaks, CA: Corwin Press.
  15. ^ Hulett, K. E. (2009). Legal aspects of special education. Upper Saddle River, NJ: Pearson Education, Inc.
  16. ^ Hulett, K. E. (2009). Legal aspects of special education. Upper Saddle River, NJ: Pearson Education, Inc.
  17. ^ Goodman, A. & Goodman, R. (2009). Strengths and Difficulties Questionnaire as a dimensional measure of child mental health. Journal of the American Academy of Child and Adolescent Psychiatry, 48(4), 400-403.
  18. ^ Pierson, C. & Dedic, B. (2010). Tier 1 case example: School-wide efficient behavior screening. In J.P. Clark & M. Alvarez (Eds.), Response to intervention: A guide for school social workers. New York: New York: Oxford University Press.
  19. ^



    Horowitz, L. M., & Ballard, E. D. (2009). Suicide screening in schools, primary care and emergency departments. Current opinion in pediatrics, 21(5), 620.
  20. ^


    Katz, C., Bolton, S. L., Katz, L. Y., Isaak, C., Tilston‐Jones, T., & Sareen, J. (2013). A systematic review of school‐based suicide prevention programs. Depression and anxiety, 30(10), 1030-1045
  21. ^


    Dowdy, E., Furlong, M., Raines, T. C., Bovery, B., Kauffman, B., Kamphaus, R. W., ... & Murdock, J. (2015). Enhancing school-based mental health services with a preventive and promotive approach to universal screening for complete mental health. Journal of Educational and Psychological Consultation, 25(2-3), 178-197.
  22. ^


    Dowdy, E., Furlong, M., Raines, T. C., Bovery, B., Kauffman, B., Kamphaus, R. W., ... & Murdock, J. (2015). Enhancing school-based mental health services with a preventive and promotive approach to universal screening for complete mental health. Journal of Educational and Psychological Consultation, 25(2-3), 178-197.
  23. ^


    Dunn, E. C., Johnson, R. M., & Green, J. G. (2012). The Modified Depression Scale (MDS): a brief, no-cost assessment tool to estimate the level of depressive symptoms in students and schools. School mental health, 4(1), 34-45
  24. ^ Levitt, J. M., Saka, N., Romanelli, L. H., & Hoagwood, K. (2007). Early identification of mental health problems in schools: The status of instrumentation. Journal of School Psychology, 45(2), 163-191.
  25. ^


    Dowdy, E., Ritchey, K., & Kamphaus, R. W. (2010). School-based screening: A population-based approach to inform and monitor children’s mental health needs. School Mental Health, 2(4), 166-176.
  26. ^ Horowitz, L. M., & Ballard, E. D. (2009). Suicide screening in schools, primary care and emergency departments. Current opinion in pediatrics, 21(5), 620.
  27. ^ Horowitz, L. M., & Ballard, E. D. (2009). Suicide screening in schools, primary care and emergency departments. Current opinion in pediatrics, 21(5), 620.
  28. ^ Williams, S. T. (2008). Mental health screening and assessment tools for children. Review of Mental Health Screening and Assessment Tools, (Oct. 2008),