Tier 1 Essentials: Building Your District’s Mental Health Continuum
by Lucille Carr-Kaffashan, Ph.D., Coleen Vanderbeek, Psy.D, LPC., Melissa Tooles, LPCMH, M.Ed
In recent years, especially since the surge in child/adolescent mental health concerns, schools have moved steadily in the direction of providing onsite mental health services for students. Perhaps the COVID-19 crisis will be recognized in years to come as the tipping point that brought schools fully into their own as a preferred site for delivering children’s behavioral health services within a Multi-Tiered System of Supports framework (MTSS).
The MTSS concept of a continuum of tiered instruction and interventions evolved over the years from prior academic models including the Response to Intervention (RTI) and Positive Behavioral Interventions and Supports (PBIS) approaches. The model calls for increasingly intensive and individualized levels of support for academics and was initially created with a focus on general education students who were not identified as qualifying for special education services. The currently popular Equity-Based MTSS model is seen as a fully inclusive 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. It mirrors a tiered public health framework for service delivery, and increasingly is being used by school leaders across the country to meet the mental health needs of troubled and dysregulated students. A mental health MTSS typically includes three tiers of support, with increasing levels of intensity. The largest and lowest level of intensity is Tier 1, best conceptualized as universal mental wellness and prevention services that are woven into all instructional materials and school activities. Students, parents/guardians, and all school personnel are considered recipients of these wellness-oriented initiatives.
The needs of students with moderate to severe symptoms often capture the most attention within resource-strained districts. It is important to consider, however, that building Tier 1 capacity can ultimately be a district’s most cost-effective endeavor as it affords the opportunity to address mental health concerns before they reach a point of extreme emotional and financial cost. It moves systems away from the all too common “wait to fail” method in favor of prevention and early intervention, and in a time when mental health resources are not sufficient to meet the growing need, it affords the opportunity to provide services to an entire school population.
Components of Tier 1 Within a Mental Health MTSS
Tier 1 of a mental health MTSS can include numerous components, the most prominent of which are:
- Universal Mental Health Screening done at specified intervals (e.g., annually) to identify students who might need support that goes beyond Tier 1 instruction and activities.
- School-Wide Programs and Presentations and the regular distribution of materials to increase mental health literacy and reduce the stigma of mental illness. Topics can include everything from suicide prevention and the effects of trauma and adverse childhood experiences (ACES), to recognizing the signs of depression, anxiety, ADHD, etc. and improving family relationships and self-regulation skills.
- High quality Social-Emotional Learning (SEL) curricula that are appropriate for each grade level and are rigorously implemented. These curricula build and strengthen skills that are part of the foundation for good mental health and resilience.
- Professional Learning and Ongoing Consultation for teachers and other school personnel 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/school culture; that develop skills for classroom-based wellness activities such as SEL and mindfulness instruction; that enhance self-awareness and self-care.
- Professional Learning for School-Based Clinical Teams to foster critical thinking skills and creative solutions for high-risk students, and to build state-of-the-art, evidence-based intervention skills.
- Parent/Caregiver Support Workshops for all families in the district to build mental health awareness and sensitivity, and to offer both practical and emotional support.
- The adoption of Positive Discipline Practices that include, e.g., a schoolwide early warning system to identify students who are disconnected, disengaged, and/or are exhibiting risky or disruptive behaviors, the elimination of suspension in all but the most severe circumstances, etc.
- Activities that Foster School Connection and a Positive School Climate for parents/caregivers, staff, school leaders, community providers and agencies, and the community-at-large.
- The adoption of activities and practices that promote Teacher and Staff Well-Being.
- Mental Health Needs Assessment and Planning Some school leadership teams have chosen to use the momentum of this watershed mental health moment by working with consultants to build internal capacity by strengthening their already existing MTSS continuum. This work entails completing a needs assessment of existing programming along the MTSS Framework in the hopes of developing a playbook for mental health service delivery for their district that focuses on processes and artifacts, areas of improvement and best-practice standards.
Why Schools?
Multi-tier frameworks based on the public health model have attracted considerable research and practical adoption in education since the 1990’s. They are undergoing yet another transformation as district leaders increasingly use these models to incorporate the delivery of mental health services within their school communities. It is well known that childhood psychiatric disorders contribute to educational failure, and vice versa. Both are associated with a range of additional adverse outcomes, including risk-taking behavior and an increased likelihood of entering the criminal justice system. Schools play a critical role in children’s development, including their cognitive and physical growth, the acquisition of social skills, and the development of character.
But why are schools the logical place to build out mental health support for America’s struggling youngsters? First, it’s already happening — school-based programs have grown so extensively in the U.S. that they now account for the majority (70–80%) of mental health services for the country’s youth. Second, since free and compulsory education is offered to children aged 5–18 in the United States, schools provide particularly convenient access points for care, reducing barriers to treatment found with traditional outpatient settings, such as transportation, financial concerns, and parental involvement. In addition, schools may be an especially effective way to promote access to care for youth who are historically underserved, such as racial or ethnic minorities. Third, there is a growing body of research evidence that supports the efficacy of school based SEL and mental health services (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4788041/). Studies examining Tier 1 prevention programs have been shown to improve student outcomes, including the reduction of aggression, anxiety, and substance abuse. When applied with consistency and fidelity, and when integrated with academic learning, these programs improve mental health, foster academic success, and contribute to a positive educational climate that promotes a sense of belonging and safety at school.
As noted by Bruns, E. J., et al., “Despite the evolution of terminology over time, it is clear that schools have long been seen as a particularly conducive setting for a public health agenda that promotes the wellness of an entire population … As such, RTI, PBIS, and MTSS are all descendants and share common core principles of the public health model. For one, the models emphasize the provision of appropriate services and supports for all students. Primary, universal, or Tier 1 prevention and promotion efforts are thus a greater focus in multi-tier models than in the “Refer-Test-Place” approach … Second, systematic surveillance, progress monitoring, and data-based decision making are core strategies at every level of support. Such data collection informs where an individual student is situated within the multi-level system and provides the basis for disability determination for students who have not responded to less intensive supports …”
Implementation Challenges
Even the most elegant program with extensive empirical support to back it will face implementation challenges. Not the least of these is that all stakeholders in a district will not necessarily prioritize mental health services. It can be hard to sell these services within districts where basic education components are already significantly under-funded. Some board members, parents, and/or community members will actively devalue mental health services and perhaps consider them an intrusion into a child’s or family’s private matters. This factor is especially relevant within the current climate in which some parents and school boards are actively debating educators about what content can be brought into the classroom, including SEL and mental health awareness curricula.
Another challenge is the current workforce crisis. Schools are short-staffed and teachers are more time-starved than ever, making it difficult to find both the time and the energy to incorporate new initiatives. And once programs are started, staff must have the focus and energy to maintain fidelity, and leadership must devote precious resources to provide ongoing training, data collection/analysis, and oversight.
Still another challenge is that students must be actively attending school to access mental health services. Anxiety and isolation created by pandemic-related school closures have contributed to an increase in school avoidant behavior, and many students who became disconnected from school for any number of reasons during the pandemic have never returned.
The implementation of universal screening brings its own challenges, including the possibility of over-identifying and labeling students, of increasing stigma, and of contributing to the over-use of psychiatric medications. Even with the most effective screening tools and protocols, it can also be a challenge to ensure that services are available to meet the demand, both in school and in the larger community.
A Recipe for Success
Based on research evaluating a community-academic partnership between the Seattle Public Schools and the University of Washington School Mental Health Assessment, Research, and Training (SMART) Center, Bruns, et al. have made ten broad recommendations for maximizing the success of a mental health MTSS. Their broad recommendations are:
1. Attend to Context. An MTSS cannot be built based on an idealized model and suite of interventions and strategies. School personnel, clinical practitioners, and community members must work to solve unique problems and priorities, with local needs, opportunities, and resources in mind.
2. Organize Strategies into a Widely Recognized Framework. Creating and widely distributing district-specific graphics or flow charts such as the common triangle depicting the three tiers of support can facilitate learning and communication.
3. Stay Connected to the Academic Mission of Schools. Mental health and academic outcomes should be closely intertwined.
4. Mobilize Knowledge from Implementation Science. Actively seek out and utilize findings from research surrounding professional development and coaching to make decisions about what types and amounts of training and coaching are necessary to create meaningful change.
5. Take Advantage of Opportunities to Integrate Care. Keep in mind that federal policy is shifting to ensure mental and physical health parity, and to favor the integration of medical and mental health services from both information sharing and service delivery perspectives.
6. Facilitate Communication Across Teams and Providers. Appropriate and timely information sharing can maximize the possibility that educational and mental health providers will use their resources wisely and collaboratively.
7. Use Indigenous Helpers. Given the shortage of trained and credentialed mental health workers, it is important for districts to collaborate effectively with outside providers and to train and mobilize the numerous professionals (school social workers, health educators, nurses, school counselors, and guidance counselors, etc.) who already exist within schools who can be oriented to delivering Tier 1 mental health services. These individuals all have professional training to support a variety of Tier 1 activities that are not clinical interventions per se.
8. Build an “Evidence-Based System” of School Supports. Take advantage of the explosion in published literature on prevention programs, treatment models, and school-based strategies and utilize findings to build a system that organizes decision-making around the use of data and evidence, with the goal of improving quality and outcomes.
9. Account for Diversity and Strive for Social Justice. Strive to make your district a place that works to minimize society’s gross racial and ethnic disproportionality.
10. Expand the Knowledge Base. Consider partnering with local universities to build and refine the evidence that school-based interventions can support positive social-emotional outcomes, maximize academic success, and foster healthy transitions to adulthood.
To supplement the broadly defined recommendations described above, consult resources such as The Tier 1 School Mental Health Quality Guide to drill down to Best Practice suggestions for each of the key components of a comprehensive Tier 1 program. And finally, remember that building sustainable mental health programs requires ongoing attention to the various state and federal funding sources available to schools. The American Rescue Plan Act that was passed in March 2021 included 170 billion dollars for school funding to build mental health capacity, but these crisis funding resources are time limited. Other bills working their way through congress, however, are designed to protect children’s mental health in the long term. These include the Student Mental Health Helpline Act, The Comprehensive Mental Health in Schools Pilot Program Act, and the Mental Health Services for Students Act.
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