Optimizing Your District’s Mental Health MTSS for Crisis Recognition and Response

By Lucille Carr-Kaffashan, PhD

Many districts have well-defined ways to manage their most vulnerable students, including both out-of-district placements and school-based MTSS Level 3 programs, but until now have devoted less attention to Level 2 and Level 1 programming. Long before the pandemic started, school personnel were noticing the dramatic increase in student mental health problems. Since early 2020, however, when the pandemic necessitated widespread school closures and a shift to remote learning, most districts have seen a growing population of students with mild to moderate mental health symptoms that are pandemic-induced and/or reflect exacerbations of previously identified mental health conditions.

There are many factors that impact student mental health at this unique point in history: the challenging return to in-person learning this past fall, the ongoing uncertainty caused by the spread of the COVID omicron variant, growing health and economic disparities, the stress associated with racism, loss, and disrupted routines, and the ever-present fear about school-based violence and aggression. For these reasons, it is critical that leadership take a step back to assess the adequacy of a district’s MTSS Level 2 and Level 1 programming, with a special emphasis on Crisis Assessment, Response, and Re-Entry.

Services Typically Included in Tier 2 and Tier 1 Levels of Support

The most notable services included in Tier 2 of a mental health MTSS are flexibly delivered Brief Treatment interventions and a well-defined process for conducting, responding to, and following up on Crisis Assessments. Brief Treatment services are appropriate for students with mild to moderate symptoms who present as low-risk, without suicidal or homicidal ideation, self-injurious behaviors, substance use, or impulse control issues. Treatment often consists of weekly group sessions for 6–8 weeks, with individual and/or family sessions added as appropriate.

Crisis Assessments are used to determine whether students are an immediate danger to themselves or others to ensure the highest level of safety for the student, the family, and the entire school community. A comprehensive Crisis Assessment Protocol is more than just one individual conducting a “crisis screening” and referral to a Psychiatric Emergency Center. Optimally it will include a set of foundational, evidence-based practices and a well-defined leadership oversight process. Best practice standards must include clear directives for managing all aspects of a student crisis, from Recognizing the signs of risk, to Managing the Crisis in the moment, to tracking and following through with the Response, to the establishment of clear Re-Entry and “Fit-To-Return” criteria and monitoring.

Crisis Assessments typically include questionnaires and interviews to identify high-risk behaviors, intent to harm, and risk factors including a history of trauma, prior aggression, and access to weapons or instruments of self-harm (e.g., razor blades, medications, alcohol, drugs). These district-based assessments can result in a referral to a community crisis screening center to further assess risk and to arrange for higher levels of care if necessary, or a referral to the in-house mental health team to determine if the student is appropriate for the district’s onsite services. A comprehensive threat assessment protocol should involve multiple parties (e.g., parents, school officials, police, clinicians) and multiple information gathering methods (e.g., clinician-conducted interviews, a review of medical and school records, interviews and testimonials, home visits) in the interest of keeping the student and the entire school community safe.

In comparison, MTSS Tier 1 Services address non-crisis situations, and typically include the use of one or more Universal Screening tools to be administered to the entire student population on a regular basis (e.g., one or two times per year) to identify students who may be struggling and can benefit from early intervention. Level 1 services also include high quality Social-Emotional Learning (SEL) curricula for each grade level with monitoring to ensure consistency and fidelity, SEL and other Professional Development Workshops and Consultations for teachers about a range of mental health topics and classroom management skills, and Parent Support Workshops to build mental health awareness and sensitivity.

The Importance of Creating and Adhering to a Comprehensive Crisis Assessment Protocol

Educators strive to provide a safe, positive, and affirming environment for every student. This goal encompasses everything from maintaining a safe physical environment, to actions supporting inclusivity and diversity, to supplying nutritious meals, to creating a finely tuned process for identifying and responding to students who might pose a threat to themselves or to others.

A seminal moment that has shaped current school safety practices was the launching of the Safe School Initiative (SSI) by the FBI and Secret Service following the mass shooting at Columbine High School in 1999. SSI provided a series of strategic recommendations to make schools safer, and to identify and understand aggressive students who make threats in schools. Following SSI’s release, Virginia-based psychologist Dewey Cornell created an evidence-based manual based on his extensive field research. The core of Cornell’s recommendations is the need to conduct a safety or threat assessment that can differentiate transient from substantive threats, a necessary distinction that dictates the appropriate course of action in the moment. Cornell and his team also emphasized the need for clear procedures and promoted a prevention model, that is, the need to address underlying problems by making it easy for students and families to access mental health and substance abuse services before a crisis develops.

The SSI findings and recommendations remain highly relevant today as school professionals struggle to support students whose mental health challenges create risk for themselves and others. Based on years of working with districts around the country, ESS recommends that each school create a Crisis Assessment, Response, and Re-Entry “Fit to Return” protocol for students who need immediate intervention and risk-assessment during the school day.

Guidelines for Creating a Crisis Assessment/Response/Re-Entry “Fit to Return” Protocol

A comprehensive Crisis Assessment, Response and Re-Entry “Fit to Return” Protocol supports districts through all aspects of the crisis screening, follow up, and re-entry process. The primary goal is to ensure that there is an evidenced-based process to ensure that no student “slips through the cracks” and that no student is sent inadvertently to crisis screening without sufficient need.

There are numerous steps that a district might consider while in the process of creating or revising its crisis response protocol:

• District leaders and clinicians should examine the crisis screening events that have occurred over the last several years, with an attempt to identify patterns and opportunities for improvement.
• School-based Crisis Counselor(s) and back-up Counselors must be identified and receive proper initial training and ongoing professional development.
• Screening Tools must be examined and selected (e.g., The Columbia Suicide screening tool and/or a proprietary crisis screening tool).
• State “Duty to Warn” regulations should be reviewed to ensure that crisis counselors know under what conditions threatened individuals and/or law enforcement professionals should be notified.
• The district’s “fit to return” letter should be reviewed and revised if needed, especially regarding the clarity and specificity of the assessing provider’s recommendations.
• A method for parent notification and consent for screening must be developed, along with a procedure for proceeding in an emergency if the parent cannot be reached.
• A communication protocol for providing the student, parents, and designated school personnel with recommendations upon completion of the screening must be developed.
• A written summary format that includes the student’s presentation, the clinician’s findings, and the clinical recommendations should be developed. This summary will be completed and shared with the crisis team and the parents. In those cases where no further intervention is recommended, a process for deciding whether the student should report back to class that day should be clarified.
• A process for coordination of care is needed for those instances when a student is referred to a crisis center or hospital for further evaluation. A “Clearance Letter” that includes all recommendations and requested accommodations should be designed for discharging providers to complete prior to re-entry.
• A re-entry process should be established for all students regardless of the level of care (including no care) that was recommended. Without a well-defined process a student’s care and/or safety plan can be fragmented, and the likelihood of another crisis is increased.
• Following re-entry, each student referred for a crisis screening should be reviewed on a weekly basis by designated administrative and clinical leadership until such time as the student’s condition is stabilized. Adherence to treatment recommendations, mental health symptoms, and academic performance are among the appropriate topics to discuss.
• Once a comprehensive Crisis Assessment, Response, and Re-Entry “Fit to Return” protocol is created or revised, a plan for training (and continually re-training) all staff must be developed, along with a process for informing parents and guardians about all aspects of the process.
• Regular staff training on recognizing mental health issues, on de-escalation strategies, and on approaching students from a trauma-informed perspective should be conducted.
• Information about crisis incidents/assessments should be aggregated and reviewed on at least a quarterly basis by designated clinical and administrative leadership.

How Schools Can Support the Mental Health of All Students

Thankfully, despite the increased acuity and incidence of mental health concerns, many students’ issues will never rise to the level of a crisis evaluation. The highly unusual mental health advisory released by the Surgeon General of the United States this past December has offered several recommendations for how schools, educators, and staff can support the mental health of all students:

• Provide a safe, positive, and affirming school environment.
• Learn how to recognize signs of changes in mental and physical health among students, including trauma and behavior changes. Take appropriate action when needed.
• Provide a continuum of supports to meet student mental health needs, including evidence-based prevention practices and trauma-informed mental health care.
• Expand the school-based mental health workforce.
• Support the mental health of all school personnel.
• Protect and prioritize students with higher needs and those at higher risk of mental health challenges, such as students with disabilities, personal or family mental health challenges, or other risk factors such as adverse childhood experiences (ACES), trauma, and poverty.

Where Do We Go from Here?

The news can seem rather dire at times, and the responsibilities of educators seem to expand by the minute, but it is important to note that schools alone are not responsible for safeguarding the mental health of our nation’s students. It will truly take a village to build the support systems that are necessary to maximize the healthy development of our nation’s children, and to address the many ills in our society that have taken such a toll on their health and well-being. A clear Crisis Assessment and Response Protocol that is closely adhered to, however, is an important lynchpin for ensuring the health and safety of individual students and the entire school community.