There is greater awareness of crises faced by youth with mental health challenges, including concern over the increasing suicide rate among children and adolescents. One question is often raised in response: How can we figure out who needs help, so we can avert a crisis? Mental health screening in schools is a strategy that can do just that. Specifically, this strategy can help identify strengths and challenges in youth that can be used to both promote positive mental health and address mental health challenges before they escalate. In fact, the earlier that mental health concerns are identified and addressed, the better the academic and social, emotional, and behavioral outcomes for students. However, to effectively conduct mental health screening requires careful planning and coordination with students, families, school staff, and community health and behavioral health providers.
What exactly is school-based mental health screening?
School-based mental health screening is the use of a systematic tool or process (e.g., teacher rating, office discipline referrals) to identify students’ strengths and needs. Rather than carrying out this process with only those at risk for displaying mental health concerns, screening is conducted for all students. That is, screening can be completed for an entire student body or for a smaller subset, such as a class or grade(s), regardless of whether they are or are not experiencing mental health concerns, so you can catch those who might be under a school’s radar.
Screening can be a one-time assessment at a certain point during the school year or can be done more frequently. When screening data are collected, it is important that the data are reviewed in a timely manner and used to help direct students to needed services and supports. Before beginning any screening process, schools should establish the staffing and infrastructure needed to quickly review data, meet with students, and make referrals (if needed) to ensure that students identified as high risk are able to access supports. Screening data can also help schools prioritize programming and action steps based on the needs of the students.
Systematic screening in schools may involve broad measures of distress or functioning or more specific measures to identify risk for a specific difficulty, such as anxiety or depression. More recent screening efforts have also involved tools that ask students about indicators of well-being and positive mental health, such as school connectedness and life satisfaction. Some measures for social determinants of mental health are also increasingly utilized, including adverse early life experiences, food and housing insecurity, and income inequality.
How to utilize school-based mental health screening?
School-based mental health screening can support a multi-tiered systems of support (MTSS) framework which are commonly implemented within schools and districts by identifying which students may benefit most from promotion and prevention strategies at Tier 1 (i.e., for all students), targeted strategies at Tier 2 (i.e., for subgroups of students), and intensive strategies at Tier 3 (i.e., for selected students) (Dowdy et al., 2015). Within a multi-tiered approach, screening may point to population-specific needs like social-emotional skill development or stress management that can be implemented universally and may buffer against the development or worsening of problems that require Tiers 2 or 3 supports. Schools can proactively address mental health for all students through identification, referral, and responsive service provision systems.
Examples of using screening in a MTSS:
- Tier 1: The strengths and needs of all students can be assessed through school mental health screening while also revealing information about school climate and schoolwide trends. For example, school mental health screening carried out at the high school level may reveal that 25% of the students are reporting high levels of stress and anxiety. As a result, the school may decide to build in lessons on healthy strategies for coping with stress.
- Tier 2 and 3: It is likely that students will be triaged into different categories of needed support following an initial school screening effort. Assessment measures can also be used for students who are identified as being at risk or already displaying mental health concerns to better understand their functioning. For example, a social-emotional health survey administered to students may help triage students reporting mild distress to a Tier 2 intervention and those reporting moderate to severe distress to a Tier 3 intervention
- Within an MTSS framework, it is estimated that approximately 80% of students will only need Tier 1 supports, 15% of students will need Tier 2 supports and 5% need Tier 3 intensive supports (Walker et al., 1996).
It is important to note that with screening comes responsibility. The Family Educational Rights and Privacy Act (FERPA) protects the privacy of students’ education records. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule protects individually identifiable health information held by covered entities, including outpatient mental health centers and hospitals. When schools and community partners collaborate on screening in schools, it is essential that confidentiality protections are addressed and transparent to youth and families. Addressing confidentiality of information requires clear consideration and up-front communication about what can be shared or not shared and with whom. Privacy considerations protect student mental health information while also recognizing the importance of sharing information when safety concerns arise. Neither HIPAA or FERPA should be considered an insurmountable barrier to screening implementation.
How do we carry out school-based mental health screening?
In general, there are six action steps that district and school teams can take to plan, implement, and evaluate mental health screening in schools:
- Build a foundation: Assemble a team, generate buy-in and support, and consider culture
- Clarify goals: Identify the purpose of mental health screening
- Identify resources and logistics: Take inventory of school- and community-based resources and staffing, timeline, budget, and administration policies and practices
- Select appropriate screening tool(s): Consider their intended use, reliability and validity, cost, time, training and technical support of the selected screening tool(s). To learn about some of the tools available to conduct mental health screening for children and adolescents, please visit the School Health Assessment and Performance Evaluation (SHAPE) System’s Screening and Assessment Library (www.theShapeSystem.com) and the American Academy of Pediatrics’ Mental Health Screening and Assessment Tools for Primary Care resource (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf).
- Determine consent and assent processes: Consider your plan to use active or passive/opt-out consent procedures, student assent, and consistent and multi-pronged messaging For example, one school district contacted all parents/guardians through sending letters home and a call to each parent/guardian explaining the upcoming screening process and offering the opportunity to opt out or obtain more information. Another district presented information about screening to families at a back-to-school night and secured active consent for screening as part of the beginning-of-year paperwork.
- Develop data collection, administration, and follow up processes: Consider electronic versus paper/pencil administration; staffing (including for manual data entry, if relevant); student privacy; data security, entry, and analysis; and systematic follow-up process
When planning for screening implementation, consider starting small (e.g., piloting with a single classroom or group of students) to work out any challenges before going to scale across an entire school or district. Involve youth, families, and other stakeholders in planning from the beginning to ensure the process is sensitive to different concerns and needs. Finally, help to ensure that whatever is being screened is relevant to the student population and that there are effective systems in place to address identified needs.
This blog was authored by Katie Moffa, Nancy Lever, and Sharon Hoover from NCSSLE partner National Center for School Mental Health.