According to the National Center for Educational Statistics (NCES; 2023), there were 7.3 million students between the ages of 3 and 21 served under the Individuals with Disabilities Education Act (IDEA) during the 2021-2022 academic year. The IDEA, signed into law in 1975, provides individualized education services to students with disabilities ensuring all students have access to a free and appropriate public education and defines 13 categories of disability (IDEA, 300.8[c]). According to the NCES (2023) most students receiving services were served under the category of specific learning disability (32%), and approximately the same number of students were provided special education services under the IDEA for behavior-related disabilities (i.e., Autism, Other Health Impairment for attention difficulties, and Emotional Disturbance).

Emotional Disturbance (ED) is defined to include difficulties with depression, anxiety, general emotional regulation, and social relationships (IDEA, 300.8 [c][4]), but this does not include students who struggle with attention deficit hyperactivity disorder (ADHD); they are often served under the category of Other Health Impairment (OHI; IDEA, 300.8 [c][9]). Further, students served under the Autism category may require mental health services as these students often experience symptoms of anxiety, depression, ADHD, and other mental illness (Hossain et al., 2020; Lecavalier et al., 2019). Students with specific learning disabilities, intellectual disabilities, and speech and language disabilities are also at risk for developing mental health difficulties (Briley et al., 2021; Buckley et al., 2020; Grigorenko et al., 2020).

Recent statistics on the prevalence of mental health difficulties in the U.S. population of children and youth suggested that approximately 25% experience a mental health disorder in a given year and approximately 33% experience a mental health disorder in their lifetimes (Merikangas et al., 2022). Many fewer students (5%) are reported to be served under the ED category defined within the IDEA (NCES, 2023). Given the current method of categorizing student disabilities for eligibility under the IDEA, it is difficult to estimate the number of students served under the IDEA who are struggling with mental health difficulties and who are receiving services to support those difficulties. One explanation is that the IDEA does not define mental health difficulties as a category of disability (Skaar et al., 2021).

Prevention and Identification Strategies

Eligibility for special education requires determination of a disability and a need for special education services (20 U.S.C. § 1414[b][2]). Beyond the basic requirements of a comprehensive evaluation to determine disability and need, the IDEA does little to guide special education evaluations (20 U.S.C. § 1414[b]). Each state developed specific special education procedures that further define how students are determined to be eligible for special education services. Iowa special education eligibility procedures are unique, and students who qualify for special education services are not determined eligible under one of the 13 categories but are deemed “eligible individuals” across several academic domains (Iowa Admin. Code r. 281-41.5). Iowa transitioned from the categorial determination of eligibility aiming to improve student outcomes based on the expression of disability in the school environment rather than a category as defined in federal law (Grimes & Stumme, 2016).

In practice, a student with a specific learning disability may have an academic expression of their disability, but may also struggle with adaptive behavioral skills, such as work completion, meeting deadlines, or participation in class discussions. The method of eligibility determination allows for this hypothetical student to receive special education services in both academic and adaptive behavior domains without needing to determine a primary disability category. As with the IDEA, there is no mental health domain; however, the behavior and adaptive behavior domains encompass mental health disorders within the Iowa special education eligibility system. Students who are determined to be eligible individuals and have social, emotional, and/or behavior needs have access to services provided under the IDEA.

The IDEA defines types of services available to support students with disabilities in accessing their educational programming, or free and appropriate public education (FAPE). Services are written into an individualized education plan (IEP; 34 C.F.R. § 300.324). There are three categories of services: specially designed instruction, supplemental aids and supports, and related services (20 U.S.C. § 1414[d][1][A]). Specially designed instruction is instruction adapted to meet the individual needs of students so they can access the general education curriculum and make progress towards general education standards (34 C.F.R. § 300.39[a][3]). Supplemental aids and supports include assistive technologies, paraprofessionals, and specialized transportation (34 C.F.R. § 300.42). Related services are provided by qualified professionals and include speech and language services, counseling services, psychological services, social work services, and physical therapy, among others (20 U.S.C. § 1401[26]).

When students struggle with mental health disorders in ways that impact their education, IEP teams determine which of the available services are necessary for the student to access their FAPE in the least restrictive environment (20 U.S.C. § 1402[14]; 20 U.S.C. § 1412[a][5]). For students who are struggling with mental health disorders, IEPs can contain a variety of services including specially designed instruction provided by a special education teacher, accommodations in general education settings, a behavioral intervention plan developed from the results of a functional behavior assessment, and related services provided by a mental health provider.

Securing school-based mental health services through special education begins with identification of a disability and educational need using a variety of assessment tools (20 U.S.C. §1414[b][2]; 20 U.S.C. § 1414[a][1][C]). Skaar, Etscheidt, and Kraayenbrink (2021) proposed a model for comprehensive special education evaluations of students who have suspected mental health disorders. They proposed that every evaluation for students with suspected mental health disorders begin with a functional behavioral assessment (FBA). FBA is not mandated by the IDEA for all behavior-related suspected disabilities, but it does provide important information about the functional relationship between the expression of the suspected disability and the school environment.

The IDEA does, however, mandate an FBA be completed if a student is removed from placement for more than 10 days as part of the manifestation determination process (20 U.S.C. § 1415[k][1][F]; Newcomer & Lewis, 2004). Once the FBA is completed, next steps are determined based on the gathered FBA data. If the function of the behavior is clear and there is no indication of a mental health disorder (based on data gathered through the evaluation process), then functional interventions matched to the hypothesized function of behavior are developed.

If, however, the function of the behavior is not clear or a mental health disorder is suspected (based on evaluation data), then supplemental mental health assessment is needed. This could include interviews targeted to gain information about specific mental health disorders (Garcia-Barrera & Moore, 2013); observations of specific environmental triggers of mental health related behaviors; and/or, mental health rating scales, such as the Behavioral Assessment System for Children (Reynolds & Kamphaus, 2015). When all assessments are concluded, interventions are designed based on the comprehensive evaluation data.

Intervention Strategies

Skaar et al. (2021) suggested that interventions addressing behavioral and mental health difficulties of students identified as eligible individuals fall into three categories: functional interventions matched to FBA results, therapeutic interventions matched to mental health need, and a combination of functional and therapeutic interventions matched to a combination of needs. Functional interventions include strategies to address the antecedents (or triggers) and consequences (or effects) of the behavior (McKenna et al., 2015) and strategies to teach alternative behaviors for the student to access desired consequences more appropriately (Hurl et al., 2016). For example, if the hypothesized function of the target behavior is for the student to escape independent schoolwork, then the functional intervention might include antecedent strategies of reducing the amount of independent work and providing choice about which schoolwork to complete first. Consequence strategies might include frequent positive reinforcement for completing schoolwork (e.g., verbal praise, thumbs up) and weekly rewards for completing schoolwork; rewards should match the hypothesized function of the behavior if possible, such as assignment forgiveness tickets. Interventions based on functional assessments (i.e., FBA) can result in moderate to large effects compared to non-functionally based interventions (Hurl et al., 2016; McKenna et al., 2016; Miller & Lee, 2013), and are often implemented by special education teachers with support from other educational professionals such as school psychologists and school social workers.

Students for whom the function of the behavior is unclear, who have a diagnosed mental health disorder, or for whom the evaluation data suggest involvement of a mental health disorder require therapeutic interventions to address their mental health difficulties (Skaar et al., 2021). Cognitive behavioral therapy is an effective therapeutic approach for students who experience symptoms of depression, anxiety, attention deficit hyperactivity disorder, and difficulties with anger management (Lochman et al., 2017; Sprich et al., 2016; Werner-Seidler et al., 2017).

Manualized treatments for individual or group therapy sessions are available to support students and can be implemented in school settings. Coping Cat is an effective manualized treatment for anxiety in children and adolescents (Lenz, 2015; O’Neil et al., 2012). Homework, Organization, and Planning Skills (HOPS) is an effective intervention for students with ADHD and includes both school and family intervention components (Langberg et al., 2012). Another option for addressing the mental health needs of students with disabilities is brief solution-focused counseling (Bond et al., 2013; Newsome, 2005), which is a strengths-based approach to teaching problem solving skills. While there are some limitations to using therapeutic approaches in school settings (e.g., removing students from instruction; Skaar & Maas, 2019), these approaches can be implemented with fidelity in school settings (Zhang et al., 2023). Mental health providers (e.g., school psychologists, school social workers) are best trained to implement these services, and their services can be written into the IEP as related services (IDEA, 300.34).

Finally, some eligible individuals will require both functional interventions and therapeutic interventions to comprehensively address their needs and for them to access their FAPE (Skaar et al., 2021). An example might be a 5th grade student who has severe anxiety that results in her missing whole and partial days of school. The FBA resulted in a hypothesized function of escaping work and social interactions, an interview with the student’s parent revealed she was recently diagnosed with anxiety by the family physician, and the results of the Multidimensional Anxiety Scale for Children (MASC-2; March, 2012) suggested the student was struggling with physical symptoms of anxiety and social anxiety symptoms. She was evaluated for special education, and the IEP team determined she was an eligible individual needing goals in behavior and adaptive behavior domains. Her goals were addressed through functional interventions supported by the special and general education teachers and related services provided by the school psychologist. Her functional interventions included choice in which school setting she would access instruction (special or general education), and she was allowed to go to the special education classroom whenever she felt her anxiety rise. She was also provided with frequent, physically distant positive praise when she remained in the general education classroom and when she was observed using her coping strategies throughout the day. The school psychologist met with her for 30 minutes weekly to provide psychoeducation about anxiety, teach relaxation strategies, and work through imaginal and in-vivo exposure therapy (i.e., cognitive behavioral therapy strategies).

Key Implications for Practice

Access to both functional and therapeutic interventions through special education is necessary to meet the needs of students with mental health disabilities, and the IDEA requires schools to ensure students access the services they need to make progress towards their social, emotional, behavioral, and academic goals (Etscheidt et al., 2024a; Yell & Bateman, 2017). Etscheidt et al. (2024a) developed six steps for securing school-based mental health services through special education programs based on best practice and case law.

1. The first step, as discussed above, is to complete a comprehensive evaluation of student mental health and the behavioral expressions and functional implications of suspected mental health difficulties.
2. The second step is to summarize students’ strengths and difficulties in the present levels of academic achievement and functional performance (PLAAFP) section of the IEP. Etscheidt et al. (2024a) emphasized the need for PLAAFP statements to be aligned with the behavioral and mental health evaluation data gathered. The PLAAFP provides a rationale for services and baseline data for goal setting.
3. Development of annual goals is the next step. Goals must be aligned with PLAAFP statements and one goal for each area of need must be developed. Etscheidt et al. (2024a) suggested goal statements target increasing positive behaviors (e.g., independent use of coping skills) and decreasing negative behaviors (e.g., elopement); and target both academic (e.g., assignment completion) and social-emotional behaviors (e.g., verbal aggression).
4. Along with goals, progress monitoring of goal attainment must be written into the IEP. Goals must be measured regularly to ensure progress, and if progress is not made, then problem solving must begin to determine why progress is not as expected. Measures used for progress monitoring of mental health related goal statements might include systematic direct observation, mastery monitoring of skills, existing school data, or Direct Behavior Ratings (Chafouleas et al., 2009; Eischeidt et al., 2024a; Joyce-Beaulieu & Sulkowski, 2015). Measures chosen to progress monitor goals should match the target behavior of the goal and the services provided. For example, if the target behavior of the goal is to increase independent use of coping skills when the student experiences anxiety in the classroom, then progress monitoring should be sensitive to changes in this behavior. A mastery monitoring measure is a good option and might include a checklist of coping skills being taught and reinforced though services on the IEP. As the student increases independent use of the coping skills listed on the checklist, progress is evident.
5. The next step is to memorialize services in the IEP that meet the mental health needs of the student and are aligned with the PLAAPF statements, goals, and progress monitoring plan. As previously stated, the IEP can include supplementary aids and services, specially designed instruction, and related services. For students with mental health difficulties, specially designed instruction and related services are often required for students to make progress on their goals (Etscheidt et al., 2024a; Skaar et al., 2021). Specially designed instruction is provided by special education teachers who are trained to provide behavioral supports for students. For example, a student may receive social skills training for 20 minutes a day either in the special education or general education classroom environment. Related services, such as counseling, psychological services, and social work services, are provided by mental health professionals. For example, a school psychologist may use cognitive behavioral therapy strategies to teach the student coping skills 30 minutes per week. The IEP team will determine which services are needed for students to access their FAPE and make adequate progress on their annual goals (20 U.S.C. § 1414[d][3]).
6. The sixth and final step to securing legally defensible, school-based mental health services within the IEP is to measure implementation fidelity of the services provided (Etscheidt et al., 2024a). If a student is not making progress on their annual goals, then one of the questions IEP teams must ask is whether the services are implemented with fidelity. Recent case law suggests that if services memorialized within the IEP are not provided as written (i.e., with fidelity), then schools may be out of compliance with the IDEA.

7. When mental health disorders are either a) part of the suspected disability due to school personnel observation and report, family report, and/or student self-report, or b) interfering with a student’s ability to access their educational program, the school team can utilize the above six steps to ensure students are provided mental health services through their special education program. This process is contingent upon the IEP team determining that these services are needed for the student to access FAPE. This is an issue of both evidence-based practice and an issue of legal and ethical practice (Etscheidt et al., 2024b).