Equity-Based MTSS Mental Health Services
By Melissa Tooles, LPCMH, Lucille Carr-Kaffashan, PhD, and Jerry Barone, Chief Clinical Officer
The mental health needs of American children and adolescents had been growing for at least a decade before the life-altering COVID-19 pandemic forced school closures in early 2020. According to the National Alliance on Mental Illness (NAMI), 1 in 5 students ages 13–18 has a diagnosable mental illness, and symptoms had been increasing in youth even though pre-pandemic rates of mental illness had remained steady in other age groups. Research points to several factors that are contributing to this surge in children’s mental health problems, including the isolating effect of technology usage, student anxiety about issues like school shootings and climate change, and the self-image and emotional dysregulation problems that can result from intense involvement with social media. The global pandemic added other layers of stress to students’ lives, including fears of illness and death, family economic pressures, and significant disruptions in all areas of life including academic, social, and family routines.
Increasingly, especially with the influx of COVID relief funds to schools, district leaders have been working to create and/or enhance school-based mental health services. To accomplish this, many have relied heavily on a conceptual framework already familiar within educational settings, the Multi-Tiered Systems of Support (MTSS). MTSS lends itself perfectly to the delivery of mental health services as it dovetails nicely with the well-known healthcare concept of a “continuum of care”.
What is an MTSS?
The Multi-Tiered Systems of Support (MTSS) framework was originated by educators to ensure that all students receive the individualized help that they need to succeed academically and behaviorally. Although definitions of MTSS vary, according to the IRIS Center, MTSS is defined as a “model or approach to instruction that provides increasingly intensive and individualized levels of support for academics (e.g., response to intervention or RTI) and for behavior (e.g., Positive Behavioral Interventions and Supports or PBIS)”. MTSS was initially conceived with a focus on general education students who were not identified as qualifying for special education services. It emerged from RTI (Response to Intervention) and problem-solving models that were designed to provide interventions to students at risk for failing one or more subject areas, to offer pre-referral information for students who might need special education services, and to identify the interventions that might address their individual needs.
The MTSS concept of a continuum of tiered instruction and interventions has evolved over the years to be fully inclusive of all students. The currently popular Equity-Based MTSS model is seen as a framework that is beneficial for all students, including those identified as students with disabilities. The Equity-Based MTSS model translates extremely well to the delivery of school-based mental health services, as it assumes that all students need to cultivate an awareness of mental health issues, those who are functioning well academically, socially, and emotionally, as well as those with the most severe and disabling symptoms.
Three Levels of Support
A mental health MTSS typically includes three tiers of support. The largest is Tier 1, best conceptualized as mental health wellness and prevention services that are woven into all instructional materials, including the district’s chosen Social Emotional Learning (SEL) curriculum, and school activities. Students, parents/guardians, and all school personnel are considered recipients of these wellness-oriented initiatives. Examples of Tier 1 activities are:
- Universal Mental Health Screening done at the beginning of each school year to identify which students might need support that goes beyond Tier 1 instruction and activities.
- School-wide programs and presentations and/or the regular distribution of mental health newsletters that provide information about reducing the stigma of mental illness, suicide prevention, trauma-informed practices, adverse childhood experiences (ACES), etc.
- Professional development activities for teachers that build their capacity to recognize the signs and symptoms of mental health disorders, to approach students from a trauma-informed perspective, and to craft a welcoming and supportive classroom culture; that develop skills for classroom-based wellness activities such as SEL and mindfulness instruction; that enhance self-awareness and self-care.
- Coaching for Teachers focused on potential triggers for students struggling with mental health issues and the development of skills focused on engagement, identifying and remediating students who may become dysregulated in their classrooms.
- A modified disciplinary system that includes a schoolwide early warning system to identify students who are disconnected, disengaged, and/or are exhibiting risky or disruptive behaviors.
- Activities that foster relationships with parents/caregivers, support staff, mentors, and community agencies.
Tier 2 in a mental health MTSS focuses on the needs of students who have self-identified, or who have been determined to have mild to moderate mental health symptoms via the school’s universal screening process, or via the observations of parents, teachers, or other school personnel. Examples of Tier 2 activities include:
- Short term individual and/or family therapy sessions to address stressors that are contributing to mental health symptoms.
- The development of student safety, wellness, and/or behavior plans that are tracked by designated school-based clinical personnel.
- Short term (6–8 session) psychoeducational groups that focus on specific topics such as coping with grief, anger management, mindfulness skills, and interpersonal effectiveness.
- Regular student check-ins, including peer-to-peer support groups, morning meetings, afternoon wrap-up sessions, etc.
- Referrals to outside resources as appropriate, e.g., to mentoring programs such as big brother/big sister, to church or other community recreation groups, to community-based mental health programs, etc.
Tier 3 services are the most intensive and are reserved for the smaller group of students with severe mental health challenges. Tier 3 programs include a variety of components to preserve student safety, to address trauma, and to build self-regulation and other skills to manage the symptoms of serious mental health disorders. These services are typically provided daily within a comprehensive Wrap-Around and/or Self-Contained Setting. Tier 3 program components include:
- Crisis assessment, intervention, and referral as needed.
- Weekly individual and family counseling sessions.
- Daily psychoeducational and/or process groups.
- Daily groups to improve study skills and executive function capacities.
- Frequent consultations between clinical and educational staff members, as well as with external service providers such as prescribing psychiatrists.
- Ongoing monitoring of student progress with treatment plan adjustments as needed.
MTSS Playbook Essentials
A MTSS Playbook can serve as a guide for districts that are interested in creating a mental health MTSS. The playbook lays out how a school district will implement MTSS in the mental health domain according to best practices and with consistency. Just as important as the end document, however, is the process of creating the playbook. A playbook creation process provides a healthy environment for the important conversations around roles, responsibilities, and processes that are necessary for a district to improve its delivery of mental health care. The following is a checklist of steps for a district considering the enhancement or development of a school based mental health MTSS:
- Conduct a school-by-school MTSS assessment, considering the mental health services that are offered at each location, identifying strengths as well as service gaps.
- Gather and analyze data about student mental health needs, including district’s aggregate data about students’ diagnoses and clinical/behavioral problems, out-of-district placements, attendance records, disciplinary actions, and crisis referral/assessment records.
- Poll students and families about service delivery needs and preferences, including parents’ privacy and other concerns about their children receiving school-based services.
- Catalogue available mental health resources within the local community; develop liaison relationships with these individuals and organizations.
- Gather feedback from teachers and parents about students’ academic, social, behavioral, and emotional challenges.
- Provide training for all staff about MTSS concepts and delivery models.
- Seek input from all key stakeholders (teachers, special services staff, school counselors, case managers, parents, etc.) about possible barriers to a successful mental health MTSS implementation. What school culture, community, financial, or other barriers exist?
- Consider available financial and human resources, prioritizing program elements based on severity of need and available resources.
- Consider state and local government regulations that dictate the standards for mental health programming.
- Identify staff with the skills and mindset that would support a successful implementation. Utilize these staff to coach and mentor others.
- Identify risk management factors and the safety nets that must be established.
- Assess the district’s typical information sharing and communication mechanisms and whether these might facilitate or hamper the acceptance of an MTSS by staff, students, and parents/caregivers.
Best Practice School-Based Mental Health Services — A Watershed Moment
Schools are an obvious and sensible choice as primary hubs for the delivery of student behavioral health care. Children typically spend 6 or more hours per day in school, and even in rural or remote areas where healthcare providers and systems are limited, there are typically always schools. School environments provide the perfect setting within which to observe and intervene with the whole child: academic achievement, self-regulation, social functioning, and physical health and development can all be monitored and addressed. Even more importantly, schools may be viewed by some families as less threatening, more accessible, and more “normal” than hospitals or healthcare facilities, thereby reducing some of the barriers to seeking mental health treatment.
To this end, it appears the time for school districts to build a set of mental health best practice programming standards along an MTSS Framework is NOW. However, the development of a comprehensive student mental health program can be daunting. The stakes are high either way: staff, financial, and person-hour resources that are needed to design and implement a program are significant, as are the costs of not addressing mental health problems that interfere with academic, social, and emotional functioning. Effective School Solutions is willing and able to help as districts consider their options and embrace their critical role in promoting student mental health.